jIjMiljMXM^I^^^^ 


Presented  in  honor  of 
Alfons   I.  Wray,  D.O.,   F.O.C.O. 


COLLEGE    OF    OSTEOPATHIC    PHYSICIANS 
\\l)  M  K(,l  (>\S  •    LOS  ANGELES,  CALIFORNIA 


DR.  L.  A 

L.ONQ  BEACH,  OAL.. 


LIPPINCOTTS  NEW  MEDICAL  SERIES 

Edited  by  FRANCIS  R.  PACKARD,  M.D. 


RONTGEN    RAYS 

AND 

ELECTRO-THERAPEUTICS  v 

• — 1 

WITH  CHAPTERS  ON  RADIUM 
AND  PHOTOTHERAPY 

BY/ 

MIHRAN  KRIKOR  KASSABIAN,  M.D. 

Director  of   the   Rontgen    Ray  Laboratory  of    Philadelphia  Hospital ;  Formerly  in  charge  of   the 
Rontgen   Ray   Laboratory    and    Instructor    in    Electro-Therapeutics   in   Medico-Chirurgical 
Hospital  and  College ;  Member  of  the  Philadelphia  County  Medical  Society ;  Penn- 
sylvania State   Medical   Society ;  American    Medical   Association ;    American 
Rontgen  Ray  Society ;  Vice-President  of  the  American  Physico-Electro- 
Therapeutic  Association  ;  New  York  Medico-Legal  Society ;  etc.,  etc. 


PHILADELPHIA  &  LONDON 
J.  B.  LIPPINCOTT  COMPANY 


M^/oo 

r 


Copyright,  1907,  by  J.  B.  Lipplncott  Company 


TO 

MY  MOTHER  AND  MY'  BROTHERS 

I  DEDICATE  THIS  VOLUME 
AS  A  TOKEN  OF  RESPECT  AND  AFFECTION. 

THE  AUTHOR. 


"  You  go  not  till  I  set  you  up  a  glass, 
Where  you  may  see  the  inmost  parts  of  you." 

HAMLET,  Act  III.  Scene  IV. 


"  In  wonder  all  philosophy  began,  in  wonder 
it  ends,  and  admiration  fills  up  the  interspace  ;  but 
the  first  wonder  is  the  offspring  of  ignorance,  the 
last  is  the  parent  of  adoration." 

COLERIDGE. 


VJ 

1 107 


PREFACE 


THE  object  of  this  book,  as  indicated  by  its  title,  is  to  present, 
clearly  and  concisely,  the  more  important  facts  pertaining  to  electro- 
therapeutics and  the  Routgeu  rays.  Notwithstanding  the  many  valuable 
and  important  treatises  extant  on  both  these  subjects,  the  author  has 
keenly  felt  the  need  of  something  more,  and  he  has  endeavored  to  offer, 
in  a  condensed  but  comprehensive  manner,  the  theories  and  applications 
of  electrical  energy,  in  its  various  forms,  to  the  domain  of  medicine. 

The  initial  portion  of  the  work  is  devoted  to  the  subject  of  electro- 
therapeutics, whose  compendious  character,  it  is  believed,  will  appeal 
to  the  practical  physician.  Beginning  with  the  definition  of  electrical 
terms,  this  division  of  the  work  gradually  leads  the  reader  to  an  elaborate 
description  of  high-frequency  currents,  which  have  recently  opened  up  so 
fertile  and  promising  a  field.  As  in  other  portions  of  the  volume,  the 
introduction  of  debatable  questions  and  mathematical  formulas  has  been 
studiously  avoided,  and  no  space  has  been  encumbered  with  the  recital 
of  fanciful  theories  or  those  of  a  controversial  nature. 

An  exhaustive  study  of  the  Eontgen  rays  follows.  The  author  has 
bestowed  much  care  to  a  description  of  the  apparatus  employed,  believing 
that  its  thorough  mastery  is  essential  to  a  complete  understanding  of  the 
subject.  The  technic  of  radio -photography  is  treated  of  at  length,  be- 
cause an  intimate  knowledge  of  this  department  is  indispensable  for  the 
production  of  successful  skiagraphs,  and  if  the  chapter  on  stereo-skia- 
graphy  seems  extensive,  it  is  due  to  the  fact  that  the  author  regards  the 
subject  as  one  of  constantly  growing  importance.  A  word  regarding 
X-ray  dosage.  Lack  of  a  standard  unit  of  measurement  in  X-ray  therapy 
has  compelled  the  lengthy  discussion  of  the  various  methods  in  vogue.  It 
is  believed,  however,  that  this  is  a  valuable  addition  to  the  work,  and 
may  perhaps  prove  a  convenience  to  many,  who  find  the  literature  on 
this  subject  to  be  widely  scattered.  Much  thought  has  been  bestowed  on 
the  techuic  of  dental  skiagraphy,  and  the  same  may  be  said  of  the  chapter 
on  the  localization  of  foreign  bodies.  "With  an  experience  of  more  than 
eight  thousand  cases  under  his  immediate  study  and  care,  the  author  has 
preferred,  wherever  possible,  to  introduce  and  quote  the  views  of  his 
confreres,  rather  than  to  obtrude  his  own  opinions  as  the  only  ones  accept- 
able. Because  of  the  importance  of  the  subject,  much  space  has  been 
assigned  to  a  study  of  the  cathode  rays,  and  to  the  terse  and  elegant 
description  of  the  Eontgen  rays,  so  simply  told  by  Eontgen  and  so  faith- 
fully translated  by  Professor  Barker  for  Harper  and  Brothers. 


^3416 


iv  PREFACE. 

The  therapeutic  value  ami  tin-  limitations  of  radium  are  being  thor- 
oughly investigated,  and  it  is  still  too  early  to  assign  any  definite  place  to 
this  remarkable  agent  in  the  practice  of  medicine.  A  space,  all  too 
brief,  is  allotted  to  the  study  of  phototherapy,  and  to  the  memorable 
discoveries  which  the  genius  of  Finsen  bequeathed  to  science. 

A  striking  feature,  which  will  materially  add  to  whatever  merit  the 
work  may  possess,  is  the  introduction,  in  its  final  pages,  of  a  study  of  the 
technic  employed  and  the  remarks  made  by  many  of  the  leading  expo- 
nents of  Rontgen  therapy  both  in  this  country  and  in  Europe. 

In  the  department  of  electro-therapeutics  the  author  has  freely  con- 
sulted the  works  of  Rockwell,  H.  Lewis  Jones,  Erb,  Hedley,  and  Snow. 

In  the  portion  devoted  to  the  Rontgeu  rays  he  has  referred  to  the 
treatises  of  Caldwell  and  Pusey,  F.  Williams,  Freuud,  Bouchard,  Isen- 
tlial  and  Ward,  and  Hyudinan. 

I  wish  gratefully  to  acknowledge  my  indebtedness  to  Dr.  Samuel 
Lewald,  of  this  city,  who,  by  his  literary  skill  and  unceasing  interest  in 
the  preparation  of  the  present  volume,  has  greatly  lightened  the  labor  of 
it.  A  word  of  thanks  is  due  my  colleagues  Drs.  Charles  L.  Leonard  and 
William  M.  Sweet;  the  former  for  many  suggestions,  the  latter  for 
valuable  advice  in  regard  to  the  chapter  on  localization.  Mr.  H.  C. 
Snook  very  kindly  offered  several  practical  hints  on  the  X-ray  apparatus. 
I  am  only  too  conscious  of  the  courtesies  shown  me  by  Dr.  Francis  R. 
Packard,  the  editor  of  Lippiucott's  Xew  Medical  Series. 

In  conclusion,  it  seems  fitting  to  remark  that  to  his  friends  and  to  the 
many  friends  of  science,  who  have  urged  him  on,  and  encouraged  him  to 
the  consummation  of  the  present  volume,  the  author  feels  profoundly 
grateful. 

MIHEAN  K.  KASSABIAN. 
PROFESSIONAL  BUILDING, 

Philadelphia,  Pa.,  June,  1907. 


CONTENTS 


PART  I. 
ELECTRO-THERAPEUTICS. 


INTRODUCTION. 

PAGE 

HISTORICAL  SKETCH  OF  THE  RISE  OF  ELECTRICITY xxix-xxxi 

ELECTRICITY  AS  A  PART  OF  THE  MEDICAL  CURRICULUM xxxi,  xxxii 


CHAPTER  I. 

ELEMENTARY  PRINCIPLES  OF  ELECTRICITY  AND  MAGNETISM. 

I.  Nature  and  Properties  of  Magnetism 33 

A.  NATURAL 33 

B.  ELECTRO-MAGNETS 33 

II.  Nature  and  Properties  of  Electricity 34 

A.  THEORY  OF  POTENTIAL 34 

(a)  Hydraulic  Analogy 34 

B.  UNITS  OF  ELECTRICAL  MEASUREMENT,  C.  G.  S.  SYSTEM 36 

(a)  Electro-static  Units 36 

(b)  Magnetic  Units 36 

(c)   Electro-magnetic  or  "  Absolute  "  C.  G.  S.  Units 37 

(d)  Practical  Units  and  Standards 37 

C.  DEFINITIONS  AND  EQUATIONS 38 

Conductivity 38 

Resistance  :   Ohm's  Law 39 

Ampere  ;  Farad  ;  Watt ;  Equations 39 

III.  Sources  of   Electrical  Energy 39 

A.  STATIC 39 

B.  GALVANIC 39,  40 

(a)  Primary  Batteries  :  Construction  and  Connection 40 

1.  Series 40 

2.  Parallel 40 

3.  Group 41 

(b)  Accumulators,  Storage  or  Secondary  Batteries 41 

Principles  ;  Varieties 41,  42 

Capacity 42 

Charging  from 

1.  Primary  Cells 43 

2.  110-Volt 44 

3.  Alternating  Current 44 

4.  Bicycle 45 

5.  Thermopiles 45 

v 


CONTENTS. 

PAGE 

C.  DYNAMIC  OR  ELECTRIC  MAINS 

(a)  Direct ^ 

(b)  Alternating 45 


D.  THERMOPILES 


45 


CHAPTER  II. 
THE  STATIC,  FRANKLINIC,  OR  FRICTIONAL  CURRENT. 

I.  The  Static  or  Influence  Machines  46 

Principles  of  Construction 46 

A.  TYPES  OF  INFLUENCE  MACHINES 47 

Theory  of  Action  (Wimshurst) 

Theory  of  Action  (Holtz) 49 

Theory  of  Action  ( Voss  or  Toepler) 50 

B.  CARE  AND  MANIPULATION  OF  STATIC  MACHINES 51 

C.  ACCESSORIES 52 

The  Leyden  Jar 52 

Electrodes 52 

Chain-Holder 63 

Muffler 54 

Preparation  of  the  Patient 54 

Polarity •  54 

Idiosyncrasy 55 

Dosage 56 

II.  The  Modes  of  Application 57 

A.  CONVECTIVE  CURRENTS 57 

Brush  Discharge  ;  Breeze  and  Spray 57 

Static  Bath  ;  Interrupted  Insulation 57 

B.  DISRUPTIVE  CURRENTS 58 

Direct ;  Indirect ;  Frictional 58 

C.  CONDUCTIVE  CURRENTS 58 

Static  Induced  Current 58 

Wave  Current  (Morton) 58,  59 

STATIC  MODALITIES  (CHART) 60,  61 

CHAPTER  III. 
GALVANIC,  CONTINUOUS,  OR  DIRECT  CURRENT. 

Galvanic  Battery  ;  Connections 62 

Types  of  Cells 63 

Care  of  Battery  ;  Charging  the  Cells  ;  Polarity 64 

Wall  Cabinet 64 

Rheostat ;  Electrodes  ;  Galvanometer ;  Milliampereineter 66 

Galvano-Faradic  Box 67 

Definition  of  Terms 67 

Methods  of  Application 68 

Central  Galvanization  ;  Gal vano- Faradization 69 

Cautery  Batteries 69,  70 

Sinusoidal  Current . .  70 


CONTENTS.  vii 

CHAPTER  IV. 
FARADIC,  INTERRUPTED,  OR  INDUCED  CURRENTS. 

PAGE 

Principles  of  Induction 71 

Faradic  Battery 71 

Medical  Induction  Coil 71,  72 

Interrupter  or  Rheotome 73 

Method  of  Application 73 

Localized  Faradization 74 

As  a  Diagnostic  Agent 74 

As  a  Therapeutic  Agent 74 

CHAPTER  V. 

I.  Cataphoric  Method 75 

II.  Hydro-Electric  Baths 77 

CHAPTER  VI. 

ELECTRO-DIAGNOSIS. 

The  Motor  Points 81 

Upper  Limb 82 

Lower  Limb 85 

Face ;  Neck 85 

Segments 88 

Usual  Nerve  Supply 88 

Hints  for  Practical  Testing 89 

Reaction  of  Degeneration 90 

Degeneration  of  Muscles 90 

Partial  Reaction  of  Degeneration 91 

Sensory  System  ;  Nerves  of  Special  Sense 91 

CHAPTER  VH. 
ELECTRO-PHYSIOLOGY. 

Influence  of  Electricity  upon  Motor  Nerves  and  Muscles 92 

Pfliiger's  Laws  of  Contraction 92 

Upon  Voluntary  Muscles 94 

Electrotonus t . .  94 

Sensory  Cutaneous  Nerves 95 

Sensory  Nerves  of  Muscles 95 

Upon  the  Special  Senses 95,  96 

Upon  the  Sympathetic  System 96 

Upon  the  Skin 97 

Upon  the  Head 97 

Upon  the  Spinal  Cord 97 

Upon  the  Abdominal  Organs 97,  98 

Electrical  Currents  in  Disease 98 


viii  CONTENTS. 

CHAPTER  VIII. 
PRACTICAL  APPLICATIONS  IN  DISEASED  CONDITIONS. 

PAGE 

I.  Cutaneous  System 99 

Acne  ;  Eczema  ;  Pruritus  ;  Alopecia ;  Sycosis 99 

Hypertrichosis 10^- 

Psoriasis  and  1'ityriasis  ;  Ringworm  and  Scleroderina  ;  Prurigo 101 

Cutaneous  Anaesthesia,  Herpes  Zoster 101 

vus  ;  Port-wine  Mark  ;  Moles  and  Warts  ;  Furuncles  and  Carbuncles,  102 

II.  Muscular  System 103 

Myaliria  :   Writer's  Cramp 103 

Torticollis  ;  Muscular  Contractions 104 

M  y asthenia  Gravis 105 

III.  Articular  System 105 

Synovitis  ;  Hydro-arthritis  ;  Rheumatoid  Arthritis 105 

Chronic  Articular  Rheumatism  ;  Gout ;  Tuberculous  Arthritis 106 

Fibrous  Ankylosis 106 

IV.  Digestive  System 107 

Vomiting  ;  Dilatation  of  Stomach 107 

Nervous  Dyspepsia 108 

Constipation— Method  of  Application 108 

Enteritis 109 

Fissure  of  the  Anus 110 

Prolapse  of  the  Rectum 110 

Hemorrhoids Ill 

Stricture  of  the  Rectum Ill 

V.  Genito-Urinary  System Ill 

Stricture  of  the  Male  Urethra 111-113 

Proetatitis 113,  114 

Paralysis  of  the  Urinary  Bladder 114,  115 

Incontinence  of  Urine  ;  Nocturnal  Incontinence 115 

Spennatorrho2a  and  Seminal  Emission 115 

Impotence 1 16 

Orchitis 116 

Nephritis 116 

VI.  Nervous  System 116 

Neuralgias :     Cephalalgia,  Tic  Douloureux,   Peripheral  Neuralgia,  Sci- 
atica   117, 118 

Paralyses :    Rheumatic  Paralysis,   Syphilitic  Paralysis,    Lead,    Arsenic, 

Opium,  etc 118 

Hemiplegia  ;  Paraplegia 118 

Facial  Paralysis  ;  Poliomyelitis  ;  Locomotor  Ataxia 119 

Chronic  Spinal  Muscular  Atrophy 119 

Epilepsy 119 

Insomnia  ;  Hysteria  ;  Hypochondriasis  and  Melancholia 120 

Insanity  ;  Neurasthenia 120 

Exophthalmic  Goitre 121 


CONTENTS.  ix 

PAGE 

VII.  Gynaecology    ll>^ 

Ltmtfotioni  ami  I'ossitiilities  in  the  Treatment  of  Diseases  of  Women....   122,  123 

A  menorrhrea 1  :M 

Dysmenorrhcea 124 

Fibroid  Tumors 124 

Ovarian  Tumors 125 

Chronic  Metritis 125 

Periuterine  Htematocele 125 

Stenosis  of  the  Cervical  Canal 125 

Subin volution  and  Atrophy 125 

Urethral  Caruncle 125 

Post-partum  Hemorrhage 125 

Vomiting  of  Pregnancy 126 

Slow  Labor 126 

VIII.  Aneurism '.   127-129 

CHAPTER  IX. 

APPLICATIONS  IN  THE  SPECIALTIES. 
I.  Rhinology  and  Laryngology 129 

Atrophic  Rhinitis  ;  Pharyngitis  ;  Ozaena , 129 

Anaesthesia  of  the  Pharynx ;  Laryngeal  Fatigue 130 

Atrophic  Pharyngitis  ;  Anosmia 130 

Asthma 131 

II.  Otology 131 

Auditory- Nerve  Deafness 131 

Chronic  Suppuration  of  the  Middle  Ear 131 

Tinnitus  Aurium 132 

Electricity  in  Otology  (Richardson) 132-134 

III.  Ophthalmology 134 

Paralysis  of  the  Muscles  of  the  Eye 134 

Blepharoepasm 134 

Cataract 135 

Electrolysis  in  Diseases  of  the  Lacrymal  Canal 135 

Retinal  Anaesthesia  and  its  Treatment  by  Voltaic  Alternatives 135 

Miscellaneous  Ophthalmic  Affections : 136 

CHAPTER  X. 

HIGH-FREQUENCY  CURRENTS. 

I.  Historical  Introduction 138 

II.  Principles  and  Apparatus 139 

Morton's  " Static  Induced  Current"  High-Frequency  Apparatus 140 

D' Arsonval  High-Frequency  Apparatus 141 

Tesla's  High-Frequency  Apparatus 142 

The  Oudin  Resonator 143 

Glass  Vacuum  Electrodes 143 

Cataphoresis  Electrodes 144,  145 


x  CONTEXTS. 

PAGE 

III.  Physical  Properties 145 

A.  IxnrcrioN  EFFECTS 145 

B.  ELECTRO-STATIC  EFFECTS 145 

C.  DYNAMIC  PROPERTIES 145 

D.  RESONANCE 146 

IV.  Methods  of  Application 146 

1.  Direct  Application    146 

2.  Indirect  Application  or  Auto-conduction  by  the  Solenoid 147 

3.  Auto-condensation 148 

4.  By  Local  Application 148 

V.   Physiological  Properties 148 

VI.  Applications  in  Various  Diseases 149-155 

Tuberculosis 149 

Gout ;  Rheumatism  ;  Obesity 150 

Hysteria 151 

Lupus  Vulgaris 151 

Rodent  Ulcer  and  Malignant  Diseases 151 

Piles,  Rectal  Fissures,  and  Pruritus  Ani 151 

Colitis 152 

Ozaena 152 

Epilepsy 153 

Skin  Diseases 153 

Trachoma 154 

Dulness  of  Hearing  and  Subjective  Noises 154 

Gonorrhoea .  155 


PART  II. 
THE  RONTGEN  RAYS  IN  DIAGNOSIS. 


Historical  Introduction   156 

1650,  Otto  von  Guericke 156 

1740,  Abbe"  Nollet 156 

1834,  Sir  W.  Snow  Harris 156 

1838,  Michael  Faraday 156 

1838,  Heinrich  Geissler 156 

1840,  Clerk  Maxwell 156 

1860,  Sir  Wm.  Thomson  (now  Lord  Kelvin) 156 

1865,  Gassiot  and  Sprengel 156,  157 

1869,  Hittorf 157 

1876,  Goldstein 157 

1877,  Warren  de  la  Rue,  Hugo  Miiller,  and  W.  Spottiswoode 157 

1879,  Sir  Wm.  Crookes 157 

1883,  Wiedemann  and  J.  J.  Thomson 157 

1883-1894,  Hertz 157 

1895,  Lenard,  Perrin,  Elster  and  Geitel,  Rontgen 157 


CONTENTS.  xi 

PAGE 

Comparative  Study  of  the  Properties  of  the  Cathode  and  the  Rontgen  Rays.  . . .  158 

CATHODE  RAYS 158 

Production  ;  Radiability 158 

Fluorescence  and  Phosphorescence 159 

Reflection,  Refraction,  and  Polarization 159 

Chemical  Effects  ;  Physiological  Effects 159 

Various  Theories 159 

RONTGEN  KAYS 160 

Production 160 

Radiability  and  Penetrative  Power 160 

Fluorescence  and  Phosphorescence 161 

Reflection,  Refraction,  Polarization,  and  Interference 162-166 

Chemical  Effects 166 

Physiological  Effects  ;  Various  Theories 167 

Visibility  of  the  Rontgen  Rays 167 

Velocity  of  Propagation  of  the  X-Rays 167 

Velocity  of  the  Rontgen  Rays 168 

Charging  Action  of  the  Rontgen  Rays 168 

CHAPTER  I. 

THE  RONTGEN-RAY  APPARATUS  AND  ITS  MANIPULATION. 

I.    The  Induction  Coil 169 

A.  FARADAY  ON  THE  ELEMENTARY  LAWS  OF  INDUCTION 169 

B.  THE  CONSTRUCTION  OF  THE  INDUCTION  COIL 171 

Primary  and  Secondary  Coil 171 

Condenser  and  Commutator 171,  172 

C.  INTERRUPTERS 172 

(a)  Mechanical 172 

Platinum 172 

Vibrating  Hammer 172 

Independent 172 

Self-Starting 173 

Vril 173 

Mercury 173 

Dipper 173 

Rotary 173 

Disk 174 

Johnston 174 

Jet 175 

(b)  Electrolytic 175 

AVehnelt 175 

Caldwell  and  Simon 178 

D.  VARIETIES  OF  INDUCTION  COILS 178 

(a)  Variable  Primary  Induction  Coil  ("  Jumbo  " ) 178,  179 

(b)  Tesla  Coil 180 

(c)  Kinraide 181-183 

(d)  Gaiffe 184 

(e)  Coil  without  Interrupter  ;  Max  Levy  ;  Grisson 184 


xii  CONTENTS. 

PAGE 

II.  Discharges  in  Partial  Vacua  and  the  Crookes  Vacuum  Tube 185 

A.  VARIETIES  TYPES,  CONSTRUCTION,  AND  PRINCIPLES 189 

(a)  Stationary  Vacuum 189 

(b)  Self-Regulating  and  Regenerative , 189 

Heat 190 

Method  by  Osmosis 194 

Mechanical  Regeneration l'-'4 

Electro-static  Regeneration 195 

Water-cooling 195 

B.  THE  QUALITY  OF  THE  X-RAYS 195 

Kind  of  Electrical  Energy  Employed 195 

Condition  of  the  Tubes 195 

Soft,  Medium,  and  Hard  Tubes 195 

Xrray8,  X2-rays,  X3-rays,  Porter 195 

Hani,  Medium,  Soft,  Very  Soft,  Albere-Schonberg 195 

Fifth  Grade,  Kienbock 196 

Osteoscope  of  Carl  Beck  ;  Spintermeter 196 

C.  CARE  OF  THE  TUBE 196 

Connecting  Leading  Wires 197 

Blackening  of  the  Tube 197 

Puncture  and  Explosion  of  Tube 198 

III.  Fluoroscope  and  Accessories 199 

A.  CONSTRUCTION  OF  THE  FLUOROSCOPE 199 

B.  SKIAGRAPHIC  TABLE 200 

C.  HOFFMAN'S  MEASURING  STAND  AND  FRAME 200 

D.  TUBE-HOLDERS 201 

E.  BOX-COVER  FOR  TUBE 202 

F.  DIAPHRAGM  AND  COMPRESSION  DIAPHRAGM 202 

IV.  Selection  and  Installation  of  the  X-Ray  Apparatus 203 

A.  SELECTION.    Hospital,  City,  Country,  Portable  Outfits 203,  204 

B.  INSTALLATION.    Connections  (Diagrams) 204-i'07 

C.  POLARITY  AND  CONNECTION  OF  TUBE 207 

Advantages  of  Static  Machine 208 

Disadvantages  of  Static  Machine 208,  209 

CHAPTER  II. 

THE  PRINCIPLES  OF  TECHNIC. 
I.  Fluoroscopy 210 

A.  METHODS  OP  EXAMINATION 210 

(a)  Screen  and  Fluoroscopic  Examinations 210 

(b)  Preparation  of  the  Patient 211 

(c)  Position  of  Tube 212 

(d)  Position  of  the  Patient 213 

(e).  Size,  Shape,  and  Intensity  of  Image  on  the  Screen 213 

B.  ADVANTAGES  OF  FLUOROSCOPY 213 

C.  DISADVANTAGES  OF  FLX-OROSCOPY  .  .  214 


CONTENTS.  xiii 

PAGE 

II.  Skiagraphy 214 

A.  SYNONYMS,  DEFINITION,  AND  NOMENCLATURE 214 

B.  THE  PATIENT 216 

History  Taking 216 

Preparation  of  the  Patient 216 

Position  of  Patient 216 

Immobilization  of  Part 217 

C.  PLATES,  THEIR  PREPARATION,  SIZE,  AND  PROTECTION 217 

Data  on  the  Negative 218 

D.  SELECTION  AND  USE  OF  THE  CROOKES  TUBE 218 

Position  of  the  Tube 218 

Form  of  the  Ray-emitting  Area  of  the  Anti-cathode 219 

Direction  of  the  Rays , 219 

Anodal  Distance  of  the  Tube  from  the  Plate 219 

E.  FACTORS  VARYING  THE  TIME  OF  EXPOSURE 220 

The  Capacity  of  the  Apparatus 220 

The  Peculiarity  of  the  Part  to  be  Examined 220 

Quality  of  the  Rays 220 

Intensifying  Screens 220 

F.  PREVENTION  OF  SECONDARY  OR  SAGNAC  RAYS 220 

Lead  Iris  Diaphragm 221 

III.  Photography 221 

Dark  Room  ;  Light 221 

Sensitive  Plates  and  Films 222 

Care  of  the  Plates 222 

A.  DEVELOPERS  ;  FORMULAS  ;  VARIETY 222 

(a)  Reducing 222 

(b)  Preservative 223 

(c)  Accelerating 223 

(d)  Restraining 224 

Tropical  Developer 224 

B.  MODUS  OPERAND!  OF  DEVELOPMENT 224 

Developing  :   Rapid  ;  Slow  Process  (Tank) ». 226 

Fixing,  Washing,  Drying,  and  Hardening 227-229 

C.  IMPROVEMENT  OF  THE  NEGATIVE 229 

Intensification 229 

General  and  Local  Reduction 230 

Causes  and  Prevention  of  Faulty  Negatives  :    Fogging,   Stains, 

Spots 231 

D.  PRINTING  (POSITIVE)  ;    TONING  AND  MOUNTING 231 

Dodging 232 

Ground-Glass  Substitute 232 

Developing  Papers 232 

Toning  Process  and  Formula 233 

Printing  and  Mounting  ;   Positives 233 

Transparencies  and  Lantern  Slides 234 


XIV 


CONTENTS. 


PAGE 

IV.  The  Interpretation  of  X-Ray  Negatives 234 

What  Constitute  Satisfactory  Negatives 234 

How  to  View  the  Negative 234,  235 

The  Proper  Light ;  Author's  Examining  Box 235,  236 

A.  FOREIGN  BODIES 236 

B.  FRACTURES  AND  DISLOCATIONS 237 

C.  DISEASES  AND  TUMORS  OF  THE  BONES 238 

D.  DISEASES  OF  THE  SOFT  STRUCTURES 238 

E.  DISEASES  OF  THE  THORACIC  ORGANS 238-240 

F.  ALIMENTARY  SYSTEM 240 

• ;.  GENITO-URINARY  SYSTEM 240-242 

V.  Stereo-Fluoroscopy  and  Skiagraphy 242 

A.  HISTORY  AND  PRINCIPLES 242,  243 

B.  STEREO-FLUOROSCOPY 243 

C.  TECHNIC  OF  STEREO-SKIAGRAPHY 244-249 

D.  METHODS  OF  VIEWING  STEREO-SKIAGRAMS 24!» 

Wheatstone 249 

Brewster 249 

Plastography 250 

E.  ADVANTAGES  OF  STEREO-SKIAGRAPHY 250 

Anatomy  ;   Surgery 251 

CHAPTER  III. 

THE  CLINICAL  APPLICATIONS  OF  THE  RONTGEN  RAYS. 
I.  The  Uses  of  X-Rays  in  Anatomy  and  Physiology 252 

A.  BLOOD-VESSELS  AND  RESPIRATORY  TRACT 252 

B.  BONES  AND  JOINTS 253,  254 

C.  PHYSIOLOGY  OF  PHONATION 255,  256 

II.  Diagnostic  Value  in  Fractures  and  Dislocations  and  Callus  Formation.  .  .  .    L'5i> 

A.  THE  ADVANTAGES  OF  THE  RONTGEN  RAY  METHOD  IN  THE  DIFFERENTIA- 

TION OF  COMPLICATED  FRACTURES 257 

B.  DISEASES  AND  TUMORS  OF  THE  BONES  AND  JOINTS 258 

C.  VALUE  IN  THE  TREATMENT  OF  FRACTURES 259 

D.  STUDY  OF  CALLUS  FORMATION 259 

Duration  and  Varieties 259 

Perfect  Apposition  of  Fragments 260 

Slight  Overlapping 260 

False  Joint 260 

Fractures  with  Extensive  Displacements 260 

Structure  of  the  Callus 260 

III.  Fractures  and  Dislocations  of  the  Upper  Extremity 260 

1 I  AND.     Fluoroscopic  Examination 260 

Skiagraphic  Examination 261 

WRIST-JOINT.    Fluoroscopic  and  Skiagraphic  Examinations 261 

LOWER  END  OF  RADIUS  AND  ULNA 261 

FOREARM 262 

ELBOW-JOINT.    Fluoroscopic  and  Skiagraphic  Examinations 263 


CONTENTS.  xv 

PAGE 

MIDDLE  THIRD  OF  THE  HUMERUS 264 

SHOULD ER-.IOI XT.     Fluoroscopic  and  Skiagraphic  Examinations 264 

Dislocations 264,  265 

CLAVICLE.    Skiagraphic  Examination 265 

SCAPULA.     Skiagraphic  Examination 265 

FRACTURES  OF  THE  SKULL.     Skiagraphic  Examination 265 

IV.  Fractures  and  Dislocations  of  the  Lower  Extremity 266 

FOOT 266 

ANKLE 267 

LEG  (MIDDLE  THIRD) 268 

KXEE-JOIXT  ;  PATELLA 268 

FEMUR  (MIDDLE  AXD  LOWER  THIRDS) 269 

HIP-JOINT 269 

THE  Os  IXNOMIXATA,  SACRUM,  AND  COCCYX 270,  271 

THE  SPINAL  COLUMN 271 

RIBS  AND  STERNUM 272 

V.   Diseases  of  the  Osseous  System 272 

A.  PATHOLOGICAL  CONDITIONS 273 

Acute  and  Chronic  Periostitis  and  Osteomyelitis 273 

Tuberculosis  of  Bone 273 

Syphilis  of  Bone 273 

Hypertrophic  Deforming  Osteitis  (Paget's  Disease) 273 

Leprosy 273 

Acromegaly 274 

Rickets 274 

Cretinism 274 

Osteomalacia 274 

Necrosis  and  Caries 274 

B.  TUMORS  OF  THE  BONES 274 

Sarcoma,  Carcinoma,  and  Cysts 275 

C.  DEFORMITIES  OF  BONES 275 

Congenital 275 

Exostoses 275 

Deformities  of  Intra-uterine  Origin 275,  276 

Diseases  and  Deformities  of  the  Spinal  Column 276 

Torticollis 276 

Pott's  Disease 276 

Amputation  Stumps 276 

Resection  of  Joints 277 

Regeneration  of  Bone 277 

VI.  Diseases  and  Tumors  of  the  Soft  Tissues 277 

Hjematomata 277 

Abscesses 277 

Myomata  and  Fibromata 278 

Enchondromata  ;  Lipomata  ;  Sarcomata  ;  Carcinomata 278 

Tumors  of  the  Brain 278 

Reports  of  Cases 279-282 

Calcareous  Deposits  in  Glands 282 


xvi  CONTENTS. 

PAGE 

VII.  The  Articular  System :>- 

A.  DISEASES  OK  THE  JOINTS 2S2 

Acute  Arthritis 282 

Acute  and  Chronic  Articular  Rheumatism 282 

Gout 282 

Tuberculous  Arthritis 283 

Coxalgia 288 

Coxa  Vara 283 

Genu  Valgum 284 

Genu  Varum 94 

B.  AHTHROPATHIES  ....'. 284 

Tabes  ;  Syringomyelia 284 

VIII.   Foreign  Bodies  and  their  Localization 285 

A.  MILITARY  SURGERY 285 

Greece-Turkish  War 285 

Chitral  Campaign 285 

Soudan 285 

Spanish-American  War 285 

South  Africa 286 

Russo-Japanese  War 286 

B.  VARIETIES  OF  FOREIGN  BODIES 286 

Transparent ;  Translucent ;  Opaque 286 

Table  of  Permeability  of  Rontgen  Rays 287 

C.  FOREIGN  BODIES  IN  THE  DIGESTIVE,  RESPIRATORY,  AND  GENITO-URINARY 

TRACTS 287 

(Esophagus 287 

Stomach 288 

Intestines 288 

Larynx,  Trachea,  and  Bronchi 288 

Genito-Urinary  Tract 288 

Foreign  Bodies  entering  from  Without 289 

D.  THE  X-RAYS  IN  OPHTHALMOLOOICAL  SURGERY 289 

Foreign  Bodies  in  the  Eye 289 

Sweet's  Method  of  Localization 290-295 

Davidson's  Method L".'-V297 

Grossman's  Method l>97;  20S 

Fox's  Method j<(s 

K.  VARIOUS  METHODS  OF  LOCATING  FOREIGN  BODIES 299 

Screen  Method 299 

Punctograph 299 

R^my's  Method 300 

Barrel's  Method 300 

Shenton's  Method 301 

Harrison's  Method 302 

Leonard's  Double  Focus  Stereoscopic  Method 002 

Triangulation  Method 303 

Grashey's  Method 3037  304)  305 


CONTENTS.  xvii 

CHAPTER  IV. 

PAGE 

APPLICATION  OF  THE  X-RAYS  IN  DISEASES  OF  THE  THORACIC  ORGANS. 
I.  Fluoroscopic  Examinations 306 

Anterior  and  Posterior  Views 306 

Lateral  and  Oblique  Views 307 

Methods  of  Examination  of  the  Lungs 307 

Normal  Heart  and  Diaphragm 308 

Measurement  of  the  Diaphragmatic  Incursion 308 

Measurement  of  the  Costal  Angle 309 

Causes  of  Restriction  of  the  Diaphragm 310 

Diseases  of  the  Diaphragm 310 

Average  Normal  Excursion  of  Diaphragm  ;    Width  of  Normal 

Heart 311 

II.  Skiagraphic  Examinations 311 

Various  Positions  of  Patient 311 

Time  of  Exposure 312 

III.  Clinical  Applications 313 

A.  DISEASES  OF  THE  BRONCHI  AND  LUNGS 313 

Bronchitis  ;  Bronchiectasis 313 

Asthma 314 

Emphysema 315 

Broncho-Pneumonia 315 

Pulmonary  Tuberculosis 315-318 

Cavitation 318,  319 

Acute  Miliary  Tuberculosis 319 

Pneumonia 320 

Atelectasis 320 

Abscess  and  Gangrene 321 

B.  DISEASES  OF  THE  PLEURA 321 

Pleurisy  with  Effusion 321 

Empyema 322 

Pneumothorax  ;  Hydro-pneumothorax  and  Pyo-pneumothorax,  323 

Subphrenic  Abscess  ;  Tumors  of  the  Thorax 323 

Enlarged  Glands 324 

IV.  Applications  of  the  X-Rays  to  the  Circulatory  System 324 

A.  FLUOROSCOPIC  EXAMINATION  OF  THE  NORMAL  HEART 324 

The  Orthodiagraph 325-328 

B.  SKIAGRAPHIC  EXAMINATION  OF  THE  HEART 328 

Size  and  Measurement  of  the  Heart ;  Cardiac  Mobility 329 

Displacement 330 

Cardiac  Atrophy,  Hypertrophy,  and  Dilatation 331 

Examination  of  the  Heart 332 

Pericarditis  (Pericardial  Effusion) 332 

Aortic  Aneurism 333 

Dilatation  of  the  Aorta  ;  Displaced  Aorta  ;  Enlarged  Glands  .  .  .  335 

Neoplasms  ;  Pulsating  Empyema  ;  Atheroma 335 

B 


CONTENTS. 

CHAPTER  V. 
APPLICATION  OF  THE  X-RAYS  IN  .DISEASES  OF  THE  ABDOMINAL  ORGANS. 

PAGE 

I.     Alimentary  System 336 

A.  (ESOPHAGUS 336 

Stricture ;  Stenosis 336 

Diverticulum  ;  Tumors 337 

B.  STOMACH  :  SIZE,  SHAPE,  AND  POSITION 337 

Examination  by  the  Aid  of  Gaseous  Distention 337 

Mechanical  Method 337 

Bismuth  Subnitrate  Method 338 

Fluoroscopic  and  Skiagraphic  Examinations  of  Stomach 338 

Time  of  Exposure 339.  340 

Transillumination 341 

C.  THE  CLINICAL  APPLICATION  OF  THE  RAYS 342 

Behavior  of  the  Stomach  during  Digestion 342 

Position  of  the  Stomach 342 

Gastroptosis 343 

Stenosis  of  the  Pyloric  End 344 

D.  INTESTINES 344 

Sounding  and  Radiography  of  the  Large  Intestine 344 

Obstruction 345 

Rectal  Imperforation 345 

Abdominal  New  Growths 346 

E.  LIVER 346 

Size  and  Location ' 346 

Biliary  Calculi 346,  347 

F.  PANCREAS 348 

G.  SPLEEN 348 

II.  The  Genito-Urinary  System 349 

A.  ORDINARY  METHODS  ;  DIFFICULTIES 349,  350 

B.  CALCULI  :  their  Specific  Gravity,  Penetrability,  and  Density 350 

Hypertrophy  ;  Atrophy 351 

Hydronephrosis  and  Pyonephrosis 351 

C.  TECHNIC  OF  RENAL  SKIAGRAPHY 352 

Preparation  of  Patient 352 

Literature  of  Renal  Calculi 352-354 

Advantages  and  Defects  of  this  Method 355 

D.  URETERAL  CALCULI 355 

Reports  of  Cases 355-359 

E.  THE  BLADDER 359 

Examination  for  Calculi 359 

Closure  of  the  Bladder,  as  shown  by  X-Rays 360 

F.  PROSTATIC  CALCULI 360,  361 


CONTEXTS.  xix 

CHAPTER  VI. 
APPLICATION  IN  THE  SPECIALTIES. 

PAGE 

I.  Obstetrics  and  Gynaecology 362 

Pelvimetry 362 

Skiagraph  of  Foetus 365 

Skiagram  of  Gravid  Uterus ; 366 

Neoplasms 367 

II.  Rhinology,  Laryngology,  and  Otology 367 

Abscess  of  the  Antrum  and  of  the  Frontal  Sinuses 368 

Foreign  Bodies  in  the  Larynx 369 

Ossification  of  the  Laryngeal  Cartilages 369 

Foreign  Bodies  in  the  Ear 369 

Abscess  of  the  Mastoid  Process 369 

CHAPTER  VII. 

APPLICATION  IN  DENTISTRY. 

I.  Apparatus  Used 370 

II.  Technic 370 

Intra-Oral 370 

Extra-Oral  or  Buccal  ;  Tousey's  Method 371 

III.  Clinical  Applications 372 

Unerupted  Teeth 372 

Necrosis  of  the  Maxilla 372 

Ankylosis  of  the  Inferior  Maxillary  Articulation 373 

Fracture  of  the  Inferior  Maxillary  Bone 373 

Broken  Instruments  ;  Root-Canal  Fillings  ;  Abscess  of  the  Antrum 373 

Alveolar  Abscess  ;  Orthodontia 374 

CHAPTER  VIII. 

THE  RONTGEN  RAYS  IN  FORENSIC  MEDICINE. 
I.  Legal  Status  of  the  X-Rays 375 

A.  ADMISSIBILITY  IN  VARIOUS  STATES 375-377 

B.  TECHNIC  OF  MEDICO-LEGAL  SKIAGRAPHY 377,  378 

C.  How  THE  SKIAGRAPHER  SHOULD  PREPARE  FOR  COURT 378-382 

II.  The  Physician's  Responsibility  in  Cases  of  X-Ray  Burn 382-387 

Medico- Legal  Aspect  of  Sterility 387,  388 


PART  III. 
RADIOTHERAPY,  RADIUM,  AND   PHOTOTHERAPY. 


CHAPTER  I. 

ACTION  OF  THE  X-RAYS  ON  BACTERIA. 
Experiments  of  Numerous  Operators 389-395 


x  CONTENTS. 

CHAPTER  II. 

HlSTOLOGICAL    CHANGES    INDUCED    BY    THE    ACTION    OF   THE    X-RAYS. 

PAGE 

I.  X-Ray  Dermatitis -   395,  398 

A.  CAUSES  OF  X-RAY  DERMATITIS 398,  399 

B.  CLASSIFICATION  OF  X-RAY  DERMATITIS 399 

C.  LATENT  STAGE;    FREQUENCY  AND  SUSCEPTIBILITY  IN   X-RAY  DERMA- 

TITIS    401-104 

D.  PATHOLOGICAL  PHYSIOLOGY 404-401  > 

E.  DURATION  OF  CHRONIC  DERMATITIS 406 

F.  PREVENTIVE  MEASURES  AGAINST  X-RAY  DERMATITIS 407, 40S 

G.  TREATMENT  OF  X-RAY  DERMATITIS 408-4 1  2 

II.  Remote  and  Indirect  Action  of  X-Rays 412 

.  STERILITY 41 2-414 

CHAPTER  III. 
CHANCES  INDUCED  IN  VARIOUS  DISEASED  TISSUES  BY  THE  RONTGEN  RAYS.  415-420 

CHAPTER  IV. 
TECHNIC  OF  RONTGEN  RAY  THERAPY. 

I.  Apparatus  and  Method  of  Treatment 420-422 

CROOKES  TUBE 422 

PROTECTION  OF  HEALTHY  PARTS 422—123 

POSITION  OF  THE  TUBE  ;  DISTANCE  OF  THE  TUBE 424 

DURATION  OF  EACH  EXPOSURE;   FREQUENCY  OF  THE  EXPOSURE 425 

FILTERS  ;  THE  DOSAGE 426 

II.  Methods  of  Measuring  X-Ray  Dosage 427 

A.  MEASUREMENT  OF  THE  ELECTRIC  CURRENTS 427 

The  Current  going  to  the  Primary  Coil 427 

Milliamperage  of  the  Secondary  Induced  Current 427,  428 

Spintermeter 429 

B.  THE  PENETRATION  METHOD 429 

The  Radiochromometer  of  Benoist 429-431 

Skiameters  and  Penetrometers  ;  Cryptoradiometer  of  Wehnelt. .  431 

C.  THE  PHYSICO-CHEMICAL  METHOD 431 

Chromoradiometer  of  Holzknecht 432 

Radiometer  of  Sabouraud  and  Noir6 432,  433 

Chromoradiometer  of  Bordier 433,  434 

Quantimeter  of  Kienbock 434 

New  Radiometer  of  Freund 435 

Precipitation  Test 436 

D.  THK  IONIZATION  METHOD 436 

lonization  of  Confined  Gases 436 

The  Radio-active  Standard  of  Phillips 437 


CONTENTS.  xxi 

PAGE 

E.  THE  PHOTOMETRIC  METHODS 438 

The  Kadiometer,  of  Courtade 438 

The  Guilleminot-Courtade  Method 438 

The  Fluorometer 438 

The  Method  of  Contrernoulins 439 

Selenium  Photometer 439,  440 

Fluorescence  of  the  Tube  and  the  Appearance  of  the  Electrodes.  440 
The  Thermometric  Method 441 

III.  Natural  Fluorescence  in  the  Human  Organism  and  its   Artificial  Produc- 
tion     441 

APPLICATION  IN  DISEASE 442,  443 

Influence  of  Photodynamic  Substances  on  the  Action  of  X-Rays,  443 

CHAPTER  V. 

THERAPEUTIC  VALUE  IN  DISEASE. 
I .     Cutaneous  Affections 444 

LUPUS  ERYTHEMATOSUS 444 

LUPUS  VULGARIS 444,  445 

N.EVUS 446 

ALOPECIA  AREATA  ;  Parasitic  Alopecia 447 

HVPERTRICHOSIS 447-449 

FAVUS  AXD  TIXEA  TOXSUHANS 449-451 

ECZEMA 451,  452 

ACXE 452 

Acne  Vulgaris 453 

Acne  Rosacea 453,  454 

SYCOSIS 454,  455 

PRURITUS  ANI  AXD  PRURITUS  VULV^: 455 

XERODERMA  PIGMEXTOSUM 455 

PSORIASIS 456,  457 

SEXILE  LEG  LTLCERS  ;  VARICOSE  VEINS 457 

HYPERIDROSIS 458 

KRAUROSIS  VULV.E 458 

LEPROSY 459 

II.  Malignant  Growths 460 

A.  EPITHELIOMA 460-464 

B.  CARCINOMA 464,  465 

Cancer  of  the  Breast 465-469 

Cancer  of  the  Sternum  ;   Cancer  of  the  (Esophagus 469 

Cancer  of  the  Larynx * 470 

Cancer  of  the  Stomach  and  Bowels 470 

Cancer  of  the  Uterus 470,  471 

Therapeutic  Action  of  the  X-Rays  in  Cancer 471— i  73 

C.  SARCOMA 473-477 

III.  Constitutional  Diseases 477 

A.  TUBERCULOSIS 477-482 

B.  LEUKEMIA  .  .  482-487 


xxii  CONTENTS. 

PAGH 

IV.  Miscellaneous  Affections 487-497 

A.  TRACHOMA  487-489 

B.  KELOID 489,  490 

C.  EXOPHTHALMIC  GOITRE 490-492 

D.  HYPERTROPHIED  PROSTATE 492 

E.  ANALGESIC  ACTION  OF  THE  RAYS 493-495 

NEURALGIA 493 

F.  EPILEPSY 495-497 

CHAPTER  VI. 
RADIUM  AND  OTHER  RADIO-ACTIVE  SUBSTANCES. 

OCCUURREXCE 498 

CHEMICAL  AND  PHOTOGRAPHIC  EFFECTS 498-500 

PHYSICAL  PROPERTIES  OF  RADIUM 500 

Penetration  ;  Fluorescence  and  Luminosity 500 

THEORETICAL  CONSIDERATIONS  :  CLASSIFICATION 501 

BIOLOGICAL  EFFECTS 501 

Bactericidal  Action 501 

Influence  of  Radium  on  Agglutination  ;  Physiological  Action. . .  502 

Effects  on  the  Nervous  System  ;  Effects  on  the  Eye 502 

RADIUM  AND  THORIUM  AS  THERAPEUTIC  AGENTS 503 

Diseases  of  the  Skin 503 

Mode  of  Retrogression  of  Cancer  Metastases  under  Radium  Rays,  504 

Reports  of  Various  Radium  Therapeutists 605-507 

Exophthalmic  Goitre  ;  Rabies  ;  Nsevus 507 

Radio-active  Treatment  with  Thorium 508 

Rheumatism 509 

CHAPTER  VII. 
PHOTOTHERAPY. 

COMPOUND  NATURE  OF  LIGHT 510,  511 

ACTION  OF  LIGHT  ON  PLANTS 511 

ACTION  OF  LIGHT  ON  BACTERIA 511,  512 

EFFECT  OF  LIGHT  ON  ANIMALS  AND  MAN 512 

THERAPEUTIC  ACTION  OF  LIGHT;  ITS  USE  AMONG  THE  ANCIENTS 513 

TREATMENT  WITH  SUNLIGHT 514 

TREATMENT  WITH  THE  INCANDESCENT  ELECTRIC  LIGHT 514,  515 

TREATMENT  WITH  THE  CONCENTRATED  ARC  LIGHT 515,  516 

THE  DERMO  OR  IRON  ELECTRODE  LAMP 516 

THE  COOPER-HEWITT  MERCURY-VAPOR  LAMP 516,  517 

THE  FINSEN  OR  RED-LIGHT  TREATMENT  OF  SMALLPOX 517-520 

Conditions  for  Success  by  Finsen's  Method 520 

BLUE  LIGHT 520 

Blue  Light  as  an  Anaesthetic 520,  521 

APPENDI X  : 

TECHNIC  OF  RONTGKN  RAY  TREATMENT.  .  .  522 


ILLUSTRATIONS 


1 .  Electric  units  illustrated  by  means  of  the  hydraulic  analogy  (Hedley) 35 

2.  Connection  of  battery  cells  in  "  series  " 40 

3.  Connection  of  the  cells  in  "  parallel " 40 

4.  Connection  of  the  cells  in  "groups " 41 

5.  Diagrammatic  view  of  the  inner  construction  of  a  storage  cell  (American 

Battery  Co.) 41 

6.  Diagrammatic  view  illustrating  the  charging  of  a  battery  by  the  ammeter 

and  volt-meter 43 

7.  Diagrammatic  view  illustrating  the  charging  of  a  battery  by  a  bank  of  lamps  44 

8.  Diagrammatic  view  illustrating  the  principles  of  influence  and  accumulation 

of  static  or  influence  machines 47 

9.  Diagrammatic  illustration  of  the  theory  of  action  of  a  Wimshurst  influence 

machine 48 

10.  Wimshurst  influence  machine 49 

11.  Toepler-Holtz  influence  machine 50 

12.  Static-disk  electrode  with  insulated  points 53 

13.  Static  massage  electrodes  for  wet  applications 53 

14.  Universal  hard-rubber  handle  for  holding  electrodes 53 

15.  Insulated  hook  for  holding  conducting  cord 53 

16.  Pole  changer  of  Betz 56 

17.  Static  breeze,  concentrated  brush  discharge,  or  spray facing  56 

18.  Static  negative  insulation  or  static  bath facing  56 

19.  Direct  spark facing  56 

20.  Indirect  spark facing  57 

21.  Friction-spark  treatment facing  58 

22.  Static  induced  current facing  59 

23.  Galvanic  cell 62 

24.  Bunsen  cell  (double  fluid) 63 

25.  Wall  cabinet  for  galvanic,  faradic,  and  sinusoidal  currents 65 

26.  Deprez-D'Arsonval  galvanometer  (milliamperemeter) 67 

27.  Galvanic,  faradic,  cautery,  and  diagnostic  lamp  battery 69 

28.  Medical  induction  coil 72 

29.  Galvanic  and  faradic  lamp  controller 73 

30.  Peterson's  cataphoric  electrode 76 

31.  Sectional  view  of  the  same 76 

32.  Three  varieties  of  cataphoric  electrodes 76 

33.  Martin's  cataphoric  electrode 76 

34.  The  four-celled  battery  of  Schnee 78 

35.  Diagrammatic  view  of  the  direction  of  current  as  is  illustrated  in  Schnee's 

four-celled  battery 79 

36.  Motor  points  of  the  arm 82 

37.  Motor  points  of  the  forearm  and  hand 82 

38.  Motor  points  of  the  arm  (front  view) 83 

xziii 


xxiv  ILLUSTRATIONS. 

FIG.  PAGE 

39.  Motor  points  of  the  forearm  and  hand  (front  view) 83 

40.  Motor  points  of  the  thigh 84 

1 1 .  Motor  points  of  the  leg  and  foot 84 

42.  Motor  points  of  the  thigh  and  leg  (posterior  view) 86 

43.  Motor  points  of  the  leg  and  foot  (inner  side) 86 

44.  Motor  points  of  the  head  and  neck 87 

45.  Motor  points  of  the  chest  and  abdomen 87 

46.  Interrupting  needle-holder  for  electrolysis 100 

47.  Roller  electrode  with  insulated  points  for  muscular  faradization 103 

48.  Double  rectal  bulb  electrode Ill 

49.  Shoemaker's  prostatic  electrolyzer 114 

50.  Vesical  electrode  for  hydro-electric  application  to  the  female  bladder 123 

51.  Goelet's  intra-uterine  electrode 123 

52.  Ozone  inhalation facing  128 

53.  Curved  sponge  electrode  for  application  to  throat 129 

54.  Electrode  for  hydro-electric  application,  post-nasal  and  pharyngeal 129 

55.  Double  sponge-tipped  ear  electrode 131 

56.  Adjustable  eye  electrode,  for  one  or  both  eyes 136 

57.  Oscillatory  nature  of  the  Leyden-jar  discharge 139 

58.  Morton's  "static-induced  current "  high-frequency  apparatus 140 

59.  D'Arsonval  high-frequency  apparatus 141 

60.  The  Tesla  transformer 142 

61 .  Diagram  of  the  Oudin  resonator facing  142 

62.  The  Oudin  resonator  and  Tesla  coil,  with  electrode facing  142 

63.  Glass  electrodes facing  143 

64.  Piffard's  glass  electrode 144 

65.  Morton's  cataphoric  electrode 144 

66.  Treatment  by  auto-conduction facing  148 

67.  Treatment  by  the  effluviation  method facing  149 

68.  Diagram  illustrating  the  principles  of  induction  (after  Donath) 170 

69.  Self-starting  interrupter facing  172 

70.  Diagrammatic   view  of  self -starting  interrupter    (Rontgen  Manufacturing 

Co.) facing  172 

71 .  Mercury  interrupter 173 

72.  Davidson's  interrupter facing  174 

73.  Johnston's  mercury  interrupter facing  174 

74.  Wehnelt  interrupter 175 

75.  Simon  interrupter 176 

76.  Friedlander  electrolytic  interrupter 177 

77.  The  Tesla  oscillator 18O 

78.  Outer  view  of  the  same 180 

79.  Lines  of  force  in  the  older  coils 182 

80.  Lines  of  force  in  Kinraide's  coil 182 

81 .  Kinraide's  diagram  of  two  coils  side  by  side 183 

82.  83.  Discharge  passing  through  low-vacuum  tubes  (Bouchard) 186 

84.  Cathode  rays  (Bouchard) 186 

85.  Deflection  of  the  cathode  rays  (Bouchard) 186 

86.  Illustration  of  the  effect  of  one  cathode  and  several  anodes  under  different 

degrees  of  vacuum  (Bouchard) 187 

87.  Illustration  of  one  of  the  phenomena  in  high  vacua, — the  rectilinear  propaga- 

tion of  the  cathode  rays  (Bouchard) 187 


I LLTJSTR  ATICXN  S.  x  x  f 

FIG.  PAGE 

88.  Essential  features  of  an  X-ray  tube 188 

89.  Queen's  self-regulating  tube 191 

90.  Midler's  regulation  tube 192 

91.  Monopol  tube ; 193 

92.  Osmosis  regulating  tube  of  Gundelach 194 

93.  Self-regulating  X-ray  tube,  operating  properly facing  194 

94.  Self-regulating  X-ray  tube,  current  running  in  wrong  direction facing  196 

95.  Villard's  venjril  tube 198 

96.  Self-regulating  X-ray  tube,  low  vacuum facing  198 

97.  Self-regulating  X-ray  tube,  punctured  or  cracked,  bulb  partially  filled  with 

air facing  200 

98.  Ordinary  diaphragm 203 

99.  Tubular  or  compression  diaphragm  (Donath) 203 

100.  Author's  table  and  tube-holder 205 

101 .  Diagrammatic  view  of  the  installation  of  the  "  jumbo  "  coil  and  its  connections 

with  the  variable  primary  coil,  as  used  by  the  author  at  the  Philadelphia 

Hospital 206 

102.  Author's  office  outfit 207 

103.  Polarity  as  determined  by  the  appearance  of  the  spark 208 

104.  Detachable  fluoroscope  and  screen 21 1 

105.  A  study  in  shadow  distortions  (fluoroscopic  or  skiagraphic)  with  correspond- 

ing density  difference 212 

106.  Envelo  developer  (Lyon  Camera  Co.) facing  226 

107.  Automatic  tray-rocker  (Rontgen  Manufacturing  Co.) facing  226 

108.  Author's  washing  tank 228 

109.  Author's  negative-viewing  box 236 

110.  Principles  of  Brewster's  refracting  stereoscope 243 

111.  Principles  of  Wheatstone's  reflecting  stereoscope 243 

112.  Technic  of  stereo-skiagraphy,  and  viewing  by  reflection  and  refraction 245 

113.  Author's  plate-changing  box 246 

114.  Wheatstone's  reflecting  stereoscope,  as  modified  by  Weigel facing  250 

115.  Prism  stereoscope  of  Walter 250 

116.  Stereo-skiagrams  of  Colles's  fracture facing  250 

117.  Inward  dislocation  of  the  first  phalanx  of  the  thumb facing  262 

118.  The  normal  hand,  taken  with  high-vacuum  tube facing  262 

119.  Fracture  of  the  scaphoid facing  262 

120.  Colles's  fracture  (antero-posterior  view) facing  262 

121 .  Colles's  fracture  (lateral  view) facing  262 

122.  Fracture  of  the  styloid  process  of  the  ulna  (supine  position) facing  263 

123.  The  same  (prone  position) facing  263 

1 24.  Typical  Colles's  fracture facing  263 

125.  Green-stick  fracture  of  the  ulna facing  266 

126.  Fracture  of  the  neck  of  the  radius facing  266 

127.  Epiphyseal  separation  and  displacement  of  the  lower  end  of  the  humerus 

facing  266 

128.  Fracture  of  the  ulna  and  displacement  of  the  head  of  the  radius facing  266 

129.  Supracondyloid  fracture  of  the  humerus facing  266 

130.  Fracture  of  part  of  inner  epicondyle,  after  forcible  reduction facing  266 

131.  Detachment  of  a  portion  of  the  external  condyle  of  the  humerus  (antero- 

posterior  view) facing  266 

132.  The  same,  in  the  lateral  view facing  266 


xxvi  ILLUSTRATIONS. 

KG.  PAGE 

133.  Detachment  of  the  supinator  longus  muscle facing  266 

134.  Epiphysitis  of  the  humeral  head facing  266 

135.  The  corresponding  normal  side facing  266 

136.  Subluxation  of  the  shoulder-joint facing  '266 

137.  Fracture  of  the  acromion  process facing  266 

138.  Fracture  of  the  acromial  end  of  the  clavicle facing  266 

139.  Fracture  of  the  metatarsal  bones facing  267 

140.  Fracture  of  the  middle  of  the  fourth  metatarsal  bone facing  270 

141.  Pott's  fracture * facing  270 

142.  Fracture  of  tibia  and  fibula,  taken  at  an  angle  between  the  antero-posterior 

and  lateral  positions facing  270 

143.  The  same,  in  the  lateral  view facing  270 

144.  Fracture  of  the  anterior  portion  of  the  patella facing  270 

145.  Detachment  of  the  tubercle  of  the  tibia facing  270 

146.  Incomplete  inter-trochanteric  fracture facing  270 

147.  Congenital  dislocation  of  the  head  of  the  left  femur facing  270 

148.  Congenital  dislocation  of  both  hips facing  270 

149.  Pathological  dislocation  of  left  hip  in  a  child facing  270 

150.  A  case  of  probable  infantile  palsy facing  271 

151.  Chronic  osteitis  with  eburnation facing  274 

152.  Osteitis  of  the  index  finger facing  274 

153.  Tuberculous  osteitis facing  274 

154.  Syphilitic  osteitis  of  the  radius facing  274 

155.  Necrosis  of  the  os  calcis facing  274 

156.  Supernumerary  thumb facing  274 

157.  Congenital  absence  of  the  ulna  and  two  fingers facing  275 

158.  Congenital  multiple  exostoses facing  275 

159.  Delayed  ossification  of  the  epiphyses facing  276 

160.  Author's  head  rest 278 

161.  Tuberculous  arthritis  of  the  knee-joint facing  284 

162.  Coxa  vara facing  284 

163.  Arthropathies  in  the  knee-joint facing  284 

164.  Penny  in  the  oesophagus facing  285 

165.  Principles  of  the  method  of  localization  (Sweet) 291 

166.  Indicating  apparatus  secured  to  the  side  of  the  head  (Sweet) 292 

167.  Outline  drawing  of  radiograph,  tube  above  the  plane  of  indicators 293 

168.  Outline  drawing  of  radiograph,  tube  below  the  plane  of  indicators 293 

169.  Sweet's  chart  for  plotting  location  of  foreign  bodies  in  the  eye 294 

170.  Mackenzie  Davidson's  localizer 295 

171 .  Fox's  localizer facing  298 

172.  The  right-angle  method  of  localization 299 

173.  "T"  scale  used  in  the  triangulation  method 304 

174.  Scheme  of  application  of  the  "T "  scale 304 

175.  Orthodiagraphic  localizer  of  Grashey 305 

176.  Diagrammatic  view  of  the  same 305 

177.  Tuberculosis  of  the  right  lung  (posterior  view) facing  318 

178.  Tuberculosis  of  the  right  lung  (anterior  view) facing  319 

179.  Moritz'  ort hodiagraph  (horizontal  position) facing  324 

180.  Moritz'  orthodiagraph  (vertical  position) facing  324 

181.  Levy-Dorn's  orthodiagraph  for  the  standing  position 327 

182.  Levy-Dorn's  orthodiagraph  for  use  in  the  recumbent  posture 328 


ILLUSTRATIONS.  xxvii 

FIG.  PAGE 

183.  Author's  table  for  skiagraphing  the  heart  and  lungs facing  328 

184.  The  same  when  used  in  the  sitting  position facing  329 

185.  Aneurism  of  the  descending  aorta facing  334 

186.  Tracing  of  the  same facing  334 

187.  Dilatation  of  the  heart,  with  aneurism  of  the  aorta facing  335 

188.  Atheroma  of  the  femoral  artery facing  335 

189.  A  case  of  gastroptosis  (bismuth  emulsion  method) facing  344 

190.  Reid's  apparatus  for  renal  skiagraphy 356 

191.  Clock  arrangement  and  break  of  the  same 357 

192.  Compression  diaphragm  of  Albers-Schonberg  (Kny-Scheerer  Co.) 358 

193.  The  same,  postero-anterior  view  (Kny-Scheerer  Co.) 359 

194.  Calculus  in  the  pelvis  of  the  right  kidney facing  360 

195.  Vesical  calculus facing  361 

196.  Varnier's  arrangement  for  radiography 364 

197.  Author's  head  rest  for  stereoscopic  work 366 

198.  Author's  head  rest  for  skiagraphing  diseases  of  the  frontal  sinuses 368 

199.  Tumor  in  the  trachea facing  368 

200.  Extra-oral  method  in  dental  skiagraphy facing  372 

201.  Unerupted  teeth facing  372 

202.  Unerupted  upper  cuspid  tooth facing  372 

203.  Delayed  eruption  of  the  upper  cuspid  tooth facing  372 

204.  Delayed  eruption  of  the  upper  cuspid  tooth  with  the  temporary  teeth  in  situ 

facing  372 

205.  Delayed  second  bicuspid,  right  side  of  lower  jaw facing  372 

206.  Delayed  second  bicuspid,  left  side  of  lower  jaw facing  372 

207.  Phosphorous  necrosis  of  the  inferior  maxilla facing  373 

208.  Chronic  alveolar  abscess  of  the  right  central  incisor  tooth facing  373 

209.  Author's  hands,  showing  result  of  chronic  X-ray  dermatitis facing  400 

210.  Author's  scheme  for  the  operator's  protection 408 

211.  Piffard  treatment  tube 421 

212.  The  bi-cathode  tube  of  Koch  of  Dresden 421 

213.  The  Kny-Scheerer  tube 421 

214.  Rosenthal's  tube  for  therapeusis 422 

215.  Connection  of  the  tube  and  Villard  valve  with  the  oscilloscope 423 

216.  Benoist's  radiochromometer 430 

217.  The  improved  Benoist  radiochromometer  as  modified  by  Pfahler  (Rontgen 

Manufacturing  Co.) facing  430 

218.  The  same,  with  its  parts  connected  (Rontgen  Manufacturing  Co.) facing  430 

219.  The  skiameter facing  430 

220.  Crypto-radiometer  of  Wehnelt 431 

221.  Kienbock's  quantimeter 435 

222.  Profile  and  full  view  of  a  patient  with  acne  rosacea facing  456 

223.  The  same,  after  fifty  irradiations facing  456 

224.  Epithelioma  of  the  nose,  before  irradiation facing  456 

22.5.  The  same,  after  irradiation facing  456 

226.  Epithelioma  of  fifteen  years'  standing,  treated  by  irradiation,  and  in  which 

radium  therapy  was  employed  as  a  control  test facing  456 

227.  Epithelioma  of  the  dorsum  of  the  hand,  before  irradiation facing  457 

228.  The  same,  after  irradiation facing  457 

229.  Tubes  and  rubber  tube  shields  for  therapy  of  the  body  cavities  (R.  V.  Wag- 

ner Co.) 471 


xxviii  I  LLfST  RATIONS. 

FIG.  PAGE 

230.  Pennington's  treatment  [cavity]  tube  (R.  V.  Wagner  Co.) 472 

231.  Cavity  tube  applied  (R.  V.  Wagner  Co.) 472 

!'.;_'.  Sarcoma  of  the  leg facing  476 

233.  Skiagraph  of  the  same facing  476 

•_•:;} .  Tuberculosis  of  the  skin facing  488 

235.  The  same,  after  irradiation facing  488 

236,  237,  238.  Groups  of  patients  irradiated  for  epilepsy facing  489 

239.  Hartigan's  radium  applicator 508 

240.  Shober's  radiode 509 

241.  Solar  spectrum,  showing  the  scheme  of  wave  lengths  of  different  radiations. .  510 

242.  Cabinet  for  the  treatment  of  disease  by  the  employment  of  incandescent 

lights  (Kny-Scheerer  Co.) facing  514 

243.  The  ^insen  method  of  treatment facing  515 

244.  The  dermo  or  iron  electrode  lamp.' 516 

J45.  Photograph  of  the  late  Professsor  Niels  R.  Finsen facing  518 

Rontgen  ray  treatment  chart facing  526 


INTRODUCTION 


HISTORICAL  SKETCH  OF  THE  RISE  OF  ELECTRICITY 

IN  the  remotest  periods  of  the  world's  history,  when  legend,  myth, 
and  fact  were  inseparably  connected,  the  phenomena  of  electricity  were 
regarded  as  symbolic  of  some  special  deity  and  formed  the  basis  of  a  na- 
tional faith.  The  philosophers  of  Greece  would  bow  in  veneration  at  the 
sound  of  the  thunderbolt,  and  in  Rome  the  ominous  herald  of  the  storm 
would  silence  the  orator  in  the  Forum.  Indeed,  to  enumerate  the  mean- 
ings and  the  attributes  ascribed  to  the  lightning  flash  and  to  the  reverber- 
ating thunder  would  be  to  rewrite  a  lengthy  and  absorbing  chapter  from 
the  pages  of  mythology. 

But  in  the  midst  of  all  this  myth  and  superstition, — this  era  of  the 
legendary  period, — arose  Thales  of  Miletus,  whose  profound  knowledge 
of  science  and  metaphysics  had  challenged  the  admiration  of  the  famous 
Phoenician  voyagers.  These  intrepid  navigators  were  accustomed  to 
sailing  the  straits  of  Hercules  in  order  to  reach  the  Baltic  Sea,  and  from 
its  desolate  waters  they  would  seize  a  delicate  substance,  fair  in  color, 
and  beautiful  in  transparency.  To  Thales  this  strange  creation  of  nature 
had  mysterious  properties.  He  named  this  precious  find  electron  or  am- 
ber, and  he  blazed  the  way  for  future  knowledge  in  discovering  that  when 
electron  was  rubbed  it  possessed  the  property  of  attracting  to  itself  vari- 
ous light  articles.  Three  hundred  years  later  Theophrastus  enlarged 
upon  the  teaching  of  Thales  and  conferred  the  name  of  "animated  gem" 
upon  this  beautiful  product  of  the  northern  seas.  Pliny  followed  with 
other  learned  dissertations  ;  and  thus  through  ages  the  mysterious  electron 
confounded  the  minds  of  philosophers,  never  once  intimating  that  the 
secrets  hidden  in  its  delicate  transparent  substance  were  the  secrets  of 
Indra,  the  Jupiter  of  the  Hindoos,  or  the  terrible  weapon  of  Jupiter 
Tonans  defiantly  passing  over  suppliant  Rome.  Centuries  passed.  King- 
doms arose  and  nations  disappeared,  but  the  studies  of  Thales  were  never 
forgotten.  Not  till  the  dawn  of  the  sixteenth  century  was  the  subject 
again  brought  forward  upon  a  scientific  basis.  In  1590  Gilbert's  work 
"De  Maguete,"  having  for  its  keynote  the  words:  "Magnus  magues 
ipse  est  globus  terrestris, ' ?  appeared  in  England,  and  the  discoveries 
made  by  this  new  champion  confused  and  terrified  its  readers.  The  super- 
natural seemed  to  envelop  its  pages ;  the  printed  words  breathed  of  the 
spiritual.  Sparks  and  flames,  shocks  and  strange  sensations,  pranced  and 


xxx  INTRODUCTION. 

teased  the  hands  and  bodies  of  hundreds  of  experimenters,  and  the  masses 
of  the  people  were  almost  unanimous  in  declaring  that  electron  was  in- 
vested with  a  soul.  Although  Physician  in  Ordinary  to  Queen  Eliza- 
beth, Gilbert  did  not  attempt  to  apply  the  knowledge  thus  gained  to 
medicine.  His  friend,  the  poet  Dryden,  immortalized  him  in  the  follow- 
ing lines  : 

"Gilbert  shall  live  till  lodestones  cease  to  draw 
Or  British  fleets  the  boundless  ocean  awe." 

Such  was  the  birth  of  the  science  of  electricity. 

But  the  magnificent  generalization  made  by  Gilbert  was  but  the 
initial  step  ;  the  scientifically  inquisitive  Otto  von  Guericke  of  Magde- 
burg quite  promptly  gave  to  the  world  a  machine  for  generating  elec- 
tricity, as  useful  at  that  period  as  was  his  indispensable  air-pump.  It 
remained,  however,  for  Stephen  Gray,  in  1730,  to  disclose  the  secrets  so 
deeply  hidden  in  this  mysterious  substance,  and  it  was  he  who  ex- 
pounded the  leading  principles  of  the  science  of  electricity.  Amazed  at 
the  wondrous  achievements  attained  by  these  later  philosophers,  Du  Fay 
and  Kollet  in  France  assiduously  applied  themselves  to  a  study  of  elec- 
trical  phenomena.  Du  Fay  suspended  himself  by  a  silken  cord,  and  was 
then  filled  with  electricity  by  Nollet ;  he  presented  his  hand  to  his  com- 
panion, when  a  brilliant  spark  shot  from  hand  to  hand,  a  phenomenon 
that  completely  baffled  the  minds  of  both  these  scientists. 

Shortly  after  this  the  whole  of  Europe  was  awe-struck  by  the  inven- 
tion of  the  Ley  den  jar.  Professor  Musschenbroek  received  its  first  full 
discharge,  and  he  wrote  to  Reaumur  that  he  would  not  suffer  a  second 
such  shock  for  the  whole  kingdom  of  France.  Seizing  upon  this  famous 
discovery,  Franklin  in  America  invented  a  battery  of  jars  capable  of 
giving  shocks  quite  analogous  to  the  terrifying  powers  of  the  thunder- 
bolt. It  was  Franklin's  contention  that  the  electricity  of  the  earth  and  air 
was  one,  and  it  was  this  positive  conviction  that  awakened  the  derision 
and  evoked  most  painful  sarcasm  from  the  Royal  Society  of  London.  Not 
dismayed  by  this  adverse  criticism,  the  persistent  American  philosopher 
constructed  a  silken  kite  containing  an  iron  point.  Attached  to  the  kite 
was  a  hemp  string  ending  in  a  silken  cord  ;  to  the  latter  was  hung  an  iron 
key.  He  selected  a  rainy  day  in  June,  1752,  for  the  experiment.  Sta- 
tioning himself  on  what  is  now  known  as  Ridge  Avenue  and  Green 
Street,  in  Philadelphia,  Franklin  flew  his  curious  apparatus  to  the 
breeze.  Suddenly  the  falling  rain  made  the  hemp  string  an  excellent 
conductor,  the  fibres  were  stirred  as  by  a  strange  impulse  ;  he  applied  his 
hand  to  the  key  and  at  once  drew  sparks  from  its  sides.  He  felt  that  he 
had  triumphed  :  he  had  seized  the  vagrant  lightning  of  the  storm  !  The 
Royal  Society  of  London  realized  that  a  mighty  scientific  achievement 
had  Ix'en  wrought,  and  made  him  a  member  and  awarded  him  their 


INTRODUCTION',  xxxi 

greatest  prize,  and  he  was  signally  honored  in  Germany,   France,  and 
Russia. 

During  the  eighteenth  century,  the  science  of  electricity  became  one 
of  the  most  important  and  interesting  branches  of  knowledge.  In  1790 
Galvaui,  through  the  convulsive  movements  of  a  dead  frog,  hanging  from 
an  iron  balcony,  brought  forward  his  great  discovery  of  galvanism.  The 
immortal  Yolta  improved  upon  Galvauf  s  teachings.  With  the  intro- 
duction of  the  voltaic  pile,  in  1800,  his  fame  spread  world- wide,  by  later 
modifications  he  formed  the  beautiful  uLa  Couronne  de  Tasses,"  the 
model  by  which  to-day  we  flash  our  messages  through  the  fathomless 
oceans.  It  was  more  than  one  hundred  years  after  Gilbert's  time,  that 
electricity  was  lirst  brought  into  use  as  a  curative  agent.  De  Haen 
(1745),  Jallabert  (1748),  and  Abbe  Xollet  (1749)  were  the  first  to  employ 
static  electricity  in  medicine.  In  1758  Benjamin  Franklin  tried  the 
action  of  the  electric  current  on  a  number  of  paralytics.  In  1759  the 
Keverend  John  Wesley,  the  famous  divine,  published  a  treatise  entitled 
The  Desideratum,  or  Electricity  made  Plain  and  Useful,  by  a  Lover  of  Man- 
kin<l  and  Common  Sense.  The  first  records  of  electrical  treatment  at  a 
London  hospital  are  found  in  the  year  1767,  when  a  static  machine  was 
installed  at  the  Middlesex  Hospital,  and  in  1777  another  was  placed  in 
St.  Bartholomew's  Hospital.  At  St.  Thomas's  Hospital  the  subject  was 
systematically  pursued  by  Mr.  John  Birch,  the  surgeon ;  and  in  1799 
he  contributed  an  essay  of  fifty  pages  on  medical  electricity  to  John 
Adams's  book,  An  Essay  on  Electricity.  The  nineteenth  century  has 
seen  the  fruits  of  these  great  labors  practically  applied.  To  enumerate 
even  a  tithe  of  the  marvellous  discoveries  and  inventions  that  form 
part  of  our  conveniences,  of  our  necessities,  of  integral  parts  of  our  every- 
day lives,  would  be  merely  to  repeat  an  oft-told  story — a  story  of  the 
great  triumphs  of  human  achievement. 


ELECTRICITY  AS  A  PART  OF   THE   MEDICAL   CURRICULUM: 

It  has  been  estimated  that  about  12,000  physicians  are  constantly 
using  some  form  of  electricity  in  their  daily  practice.  The  question 
nat  u rally  arises,  Why  doesn't  the  subject  of  medical  electricity  form  part 
of  the  college  curriculum?  Without  some  theoretical  and  practical 
knowledge  of  the  science,  how  can  the  physician  hope  to  apply  a  current 
intelligently  or  know  when  its  application  is  advantageous  I  Is  not  this 
ignorance  of  its  principles  and  practical  workings  responsible  for  its  being 
classed  in  the  charlatan's  armamentarium  and  its  administrator  desig- 
nated a  quack?  To  understand  medical  electricity  the  tyro  must  begin 
in  the  laboratory.  He  must  there  study  the  physics  of  electricity  and 
magnetism  ;  he  must  study  electrical  appliances  for  creating  energy. 


xxx ii  1NTRO1MVTION. 

IJesides  these  tiling  he  should  diligently  inquire  as  to  the  resistances 
encountered  in  the  human  body,  the  electrolysis  resulting  in  living  tissues, 
the  range  of  voltage,  etc.  He  needs  to  be  trained  especially  in  what  may 
be  termed  the  physiological  action  of  the  various  currents  and  their 
therapeutic  values.  Indeed,  if  but  one  hour  daily  for  a  single  term  be 
devoted  to  the  study  of  the  mechanism  of  the  apparatus,  to  the  connection 
of  the  wires,  the  nature  of  the  current,  etc.,  and  a  corresponding  limited 
number  of  hours  be  devoted  in  a  succeeding  term  to  the  therapeutic 
application  of  the  science,  it  is  more  than  likely  that  a  correct  apprecia- 
tion of  the  study  will  be  meted  out  to  it,  and  the  professed  specialists 
who  are  now  duping  the  unwary  would  be  forced  to  retire  ignomiuiously 
from  the  field. 


PRACTICAL 
ELECTRO-THERAPEUTICS 


PART   I 
ELECTRO-THERAPEUTICS 


CHAPTER  I 

THE  ELEMENT  A  EY  PRINCIPLES  OF  ELECTRICITY  AND 

MAGNETISM. 

IN  the  following  paragraphs  an  effort  has  been  made  to  present,  in  a 
space  succinct  yet  commensurate  with  the  importance  of  the  subject,  the 
underlying  principles  of  electricity  and  magnetism,  embracing  the  more 
usual  terms,  tables  of  units,  sources  of  energy,  and  the  fundamentals  of 
the  science  necessary  to  an  understanding  of  its  application  to  medicine 
and  surgery.  Clearness  of  expression  has  been  aimed  at  rather  than  a 
detailed  scientific  and  mathematical  exposition  of  every  term  employed. 
Those  interested  in  a  more  elaborate  study  of  these  principles  are  referred 
to  the  standard  works  on  natural  philosophy  and  electricity. 

I.  Nature  and  Properties  of  Magnetism. 

The  nature  of  magnetism  is  more  or  less  closely  allied  to  that  of  elec- 
tricity. The  term  u magnet"  is  supposed  to  originate  from  the  Greek 
word  il  Magnesia,"1  a  principality  of  ancient  Greece,  where  deposits  of 
magnetite  were  first  discovered.  Chemically  this  is  known  as  magnetic 
iron  ore  (Fe3O4). 

Magnets  are  of  two  kinds  : 

(a)  Natural. 

(b)  Artificial. 

Experiments  have  demonstrated  that,  when  steel  bars  are  applied  to 
lodestoues  or  other  magnets,  they  become  magnetized,  and  the  original 
magnet  suffers  no  loss  of  magnetic  property.  Magnets  made  in  this 
manlier  are  called  i •  artificial  magnets."  The  original  lodestoues,  from 
their  inherent  magnetic  properties,  an-  designated  ''natural  magnets." 
Chemically  the  substance  is  known  as  "magnetite." 

3  33 


34  ELECTRO-THERAPEUTICS. 

Magnetism  may  be  temporary  or  permanent.  Temporary  magnetism 
is  magnetism  remaining  only  tor  a  short  time,  as  in  soft  iron. 

Permanent  magnetism,  as  the  name  indicates,  permanently  resides 
in  the  magnet,  as  in  steel. 

ELECTRO-MAGNETS. 

When  a  bar  of  soft  iron  has  wound  around  it  a  coil  of  wire  for  the 
purpose  of  establishing  a  magnetic  field,  we  obtain  an  electro-magnet. 
Soft  iron  is  almost  universally  employed  in  the  manufacture  of  electro- 
magnets. The  use  of  hard  steel  with  a  similar  strength  of  current  yields 
far  less  magnetic  force. 

II.  Nature  and  Properties  of  Electricity. 

Electricity  (derived  from  the  Greek  rj^xrpo-^  amber)  is  the  term 
applied  to  a  certain  invisible  agent  known  to  us  only  through  its  peculiar 
behavior.  The  early  scientists  held  that  electricity  was  a  fluid  ;  later  ex- 
periments tended  to  show  that  it  beLaved  like  an  incompressible  liquid, 
and  in  other  ways  resembled  a  gas  highly  attenuated  and  without  weight. 
In  the  light  of  present  knowledge,  the  fluid  theories  have  been  abandoned, 
and  it  is  now  generally  accepted  that  the  peculiar  phenomena  are  the  re- 
sult of  some  strain  or  other  action  in  the  ether,  the  latter  being  supposedly 
a  fluid  medium  that  exists  in  all  parts  of  the  universe — in  gases,  solids, 
and  liquids. 

A.  THEORY  OF  POTENTIAL. 

The  laws  which  concern  the  magnitude  and  measurement  of  electrical 
quantities  are  very  difficult  to  explain.  That  branch  of  electrical  science 
dealing  with  the  measurements  of  electrical  charges  is  called  electro-statics. 
Many  of  the  less  complicated  electrical  phenomena  may  be  conveniently 
illustrated  by  the  action  of  fluids,  though  it  must  be  remembered  that 
such  comparisons  are  only  relative,  and  introduced  to  facilitate  the  easy 
mastering  of  electricity.  Electrical  potential,  or  electro-motive  force  ( writ- 
ten thus — E.  M.  F. ),  is  that  property  possessed  by  a  body  by  means  of 
which  an  electric  current  is  enabled  to  pass  from  it,  through  some 
other  medium,  into  another  body.  In  order  to  simplify  the  theory  of 
potential,  it  is  essential  to  notice  the  elementary  laws  governing  electrical 
force. 

Hydraulic  Analogy. — In  order  to  simplify  the  term  "potential." 
let  us  assume  the  following  analogy  between  electricity  and  water. 
L<-t  us  suppose  two  reservoirs  (both  partly  tilled  with  water  at  different 
levels  and  connected  with  each  other  by  means  of  tubing.  Evidently  the 
water  in  the  reservoir  placed  at  the  higher  level  will  flow  through  the 
pipe  into  the  lower  reservoir.  The  flow  is  due  to  difference  in  levels 


ELECTRICITY   AND   M  A<  iNKTISM.  35 

producing  pressure  (or  motive  force  .  measured  by  the  difference  in  alti- 
tude (or  potential)  between  the  water  contained  in  the  two  reservoirs. 
When  the  two  reservoirs  are  placed  at  the  same  level,  no  difference  in 
pressure  will  exist;  hence,  no  water  will  llo\\-  from  the  one  reservoir  to 
the  other.  If  we  substitute  the  word  "potential"  for  "level,"  we  then 
employ  the  common  electrical  term. 

Imagine  two  charged  bodies  to  be  connected  with  each  other  by  wire  r 
a  flow  of  current  takes  place  from  the  positive  to  the  negative  charged 
body  :  this  is  possible  because  of  a  difference  in  the  potential  in*  the  two 
bodies.  Allowing  that  the  positive  charged  body  is  at  a  higher  potential 
(or  level )  than  the  one  charged  negatively,  we  must  state  that  the  flow  of 


IVOLT 


HATE. OF  FLOW —curvrvEHT  i  AMR 


WOI\K  DONE.  1  JOULE 

I\ATE  AT  WHICH  WORK 
Fi>  DONE.  1  WM1 


FIG.  1.— Electrical  units  illustrated  by  means  of  the  hydraulic  analogy.     (Hedley.i 

current  results  from  the  difference  in  the  potentials,  thus  creating  an  elec- 
trical pressure  or  electro-motive  force.  The  fact  that  there  is  a  flow  of 
current  from  a  higher  to  a  lower  potential  must  not  be  overlooked.  From, 
the  foregoing  remarks  it  may  be  assumed  that  no  flow  of  current  takes 
place  between  the  bodies  when  they  are  at  equal  potentials.  Whenever 
a  stream  of  water  falls  from  a  higher  to  a  lower  level,  it  will  perform  a 
certain  amount  of  work  in  its  course  downward, — i.  e.,  it  has  acquired  a 
certain  amount  of  potential  force,  and,  besides,  the  difference  of  level  can- 
not be  restored  without  expending  a  certain  amount  of  work.  For  every 
pound  of  water  that  is  lifted  through  a  difference  of  level  equal  to  a  foot, 
one  foot-pound  of  work  is  done,  no  matter  what  the  shape  of  the  path 
may  be  by  which  the  elevation  of  the  water  to  a  higher  level  is  accom- 
plished. Likewise,  electricity  cannot  be  transferred  from  one  body  to 


36  ELECTKO-THKkAPFJ'TK  s. 

another  at  a  higher  potential  without  requiring  a  certain  amount  of  work 
to  be  accomplished.  The  term  potential,  tin  nigh  relative,  must  be 
considered  as  meaning  a  force  or  power  to  do  work.  For  instance,  if  we 
lift  a  one-pound  body  five  feet  high  against  the  force  of  gravity,  the 
weight  of  the  pound-body  in  turn  can  accomplish  five  toot  pounds  of 
work  in  falling  to  the  ground.  In  the  strictest  sense  of  the  term,  poten- 
tials are  relative ;  hence  it  is  always  the  difference  of  potential  with 
which  we  are  dealing. 

- 

B.  UNITS  OF  ELECTRICAL  MEASUREMENT. 

C.  G.  S.  System. — Electricians  have  universally  agreed  to  adopt  a 
system  of  measurement  based  upon  three  fundamental  units  :  namely, 
the  centimeter, — the  unit  of  length  ;  the  gramme, — the  unit  of  weight  or 
mass ;  and  the  second, — the  unit  of  time.  All  other  units  are  derived 
from  these  three,  and  are  known  as  derived  units,  one  of  the  most  impor- 
tant of  these  being  the  unit  of  force,  called  the  dyne.  The  dyne  is  that 
force  which  when  acting  for  one  second  of  time  on  a  mass  of  one  gramme 
conveys  to  it  a  velocity  of  one  centimeter  per  second. 

(a)  Electro-static  Units. — (1)  The  unit  of  electro -static  quantity  is 
that  quantity  of  electricity  which,  when  placed  at  a  distance  of  one  centi- 
meter (in  the  air)  from  a  similar  and  equal  quantity,  repels  it  with  a 
force  equal  to  one  dyne. 

(2)  The  unit  of  electro-static  potential  is  equal  to  the  unit  of  work 
done  in  moving  a  unit  of  positive  electricity  against  the  electric  forces. 

(3)  The  electro -static  unit  of  difference  of  potential  is  that  difference 
existing  between  two  points  when  it  requires  the  expenditure  of  one  erg 
of  work  to  bring  a  positive  unit  of  electricity  from  one  point  to  the  other 
against  the  electric  force. 

(4)  The  electro-static  unit  of  capacity  is  that  conductor  which  requires 
a  charge  of  one  unit  of  electricity  to  bring  it  up  to  unit  potential. 

(5)  By  electro-motive  intensity  is  meant  the  electric  force  of  intensity 
of  an  electric  fluid  at  any  point,  being  measured  by  the  force  which  it 
exerts  on  a  unit  charge  placed  at  that  point. 

(b)  Magnetic  Units. — (1)  The  unit  magnetic  pole  is  one  of  such  a 
strength  that  when  placed  at  a  distance  of  one  centimeter  (in  the  air) 
from  a  similar  pole  of  equal  strength,  repels  it  with  a  force  of  one  dyne. 

(2)  Magnetic  pnti'iitialis  measured  by  the  amount   of  work  done  in 
moving  a  unit  magnetic  pole  against  the  magnetic  forces. 

(3)  Unit  difference  of  magnetic  potential  exists  between  two  points 
when  it  requires  the  expenditure  of  one  erg  of  work  to  bring  a  unit  mag- 
netic pole  from  one  point  to  the  other  against   the  magnetic  forces — 
magneto- motive  force  being  measured  in  the  same  units  as  difference  of 
magnetic  potential. 


ELECTRICITY  AND  MAGNETISM.  37 

(4)  The  intensity  of  magnetic  field  is  measured  by  the  force  it  exerts 
upon  a  unit  magnetic  pole  ;  hence, 

(5)  Unit  intensity  of  field  is  that  intensity  of  a  field  which  acts  on  a 
unit  pole  with  a  force  of  one  dyne,  the  term  gauss  having  been  proposed 
for  this  unit. 

(6)  Magnetic  flux,  or  total  induction  of  magnetic  lines,  is  equal  to  the 
intensity  of  field  multiplied  by  area — its  unit  being  equal  to  one  magnetic 

line. 

(7)  Magnetic  reluctance  is  the  ratio  of  magneto-motive  force  to  mag- 
netic flux. 

(c)  Electro-magnetic  or  "  Absolute  "  C.  G.  S.  Units. — The  pre- 
ceding magnetic  units  give  rise  to  the  following  set  of  electrical  units,  in 
which  the  strength  of  currents,  etc.,  is  expressed  in  magnetic  measure, 
according  to  the  ceutimeter-gramme-second  system  : 

(a')  A  current  has  a  unit  of  strength  when  one  centimeter  length  of 
its  circuit  bent  into  an  arc  of  one  centimeter  radius  exerts  a  force  of  one 
dyne  of  a  unit  magnet- pole  placed  at  the  centre. 

(&')  Unit  of  difference  of  potential  exists  between  two  points  when  it 
requires  the  expenditure  of  one  erg  of  work  to  bring  a  unit  of  positive 
electricity  from  one  point  to  the  other  against  the  electric  force. 

(c')  A  conductor  is  said  to  possess  a  unit  resistance  when  unit  differ- 
ence of  potential  between  its  ends  causes  a  current  of  unit  strength  to 
flow  through  it. 

(<f  )  Unit  of  quantity  of  electricity  is  that  quantity  which  is  conveyed 
by  unit  current  in  one  second. 

(e1)  Unit  of  capacity  requires  one  unit  quantity  to  charge  it  to  unit 
potential. 

(/')  f'1^  °f  induction  is  such  that  unit  electro-motive  force  is 
induced  by  the  variation  of  the  current  at  the  rate  of  one  unit  of  current 
per  second. 

(d)  "  Practical    Units    and  Standards.1 — Several  of  the  above 
'  absolute '  units  in  the  C.  G.  S.  system  would  be  inconveniently  large 
and  others   inconveniently  small  for  practical   use.     The  following  are 
therefore  chosen  as  practical  units  : 

"  (1)  Resistance. — The  Ohm,  =  109  absolute  units  of  resistance  (and 
theoretically  the  resistance  represented  by  the  velocity  of  one  earth-quad- 
rant per  second)  but  actually  represented  by  the  resistance  of  a  uniform 
column  of  mercury  106.3  centimeters  long  and  14.4521  grammes  in  mass 
at  0°  C.  Such  a  column  of  mercury  is  represented  by  a  l standard'  ohm. 

1  An  International  Congress  of  Electricians  met  at  the  Columbian  Exposition,  at 
Chicago,  in  1893  for  the  purpose  of  adopting  practical  and  standard  electrical  units. 
These  commissioned  delegates  of  many  countries  agreed  upon  the  following  eight 
definitions  of  terms. 


38  ELECTRO-THERAPEUTICS. 

11  (2)  Current.  —  The  Ampere  <  formerly  called  the  'weber'), 
=  10  —  '  absolute  units;  practically  represented  liy  the  current  which 
deposits  silver  at  the  rate  of  0.001118  gramme  per  second. 

11  (3)  Electro-  mot  ire  Force.—  The  Volt,  ==  10s  absolute  units,  is  that 
E.M.F.  which  applied  to  1  ohm  will  produce  in  it  a  current  of  1  ampere  : 
being  »«  of  the  E.M.F.  of  a  (Mark  standard  cell  at  15°  C. 


"  (4)  Quantity.  —  The  Coulomb,  =  10'  absolute  units  of  quantity  ; 
being  the  quantity  of  electricity  conveyed  by  1  ampere  in  one  second. 

"(5)  CajHieifi/.  —  The  Farad,  =-  10  —  9  (or  one  one-thousand-  mill- 
ionth) of  absolute  unit  of  capacity  :  being  the  capacity  of  a  condenser  such 
as  to  be  chauged  to  a  potential  of  1  volt  by  1  coulomb.  The  micro-fa  rod 
or  millionth  part  of  1  farad  =  1015  absolute  units. 

"  (6)  Work.  —  The  Joule,  ==  107  absolute  uuits  of  work  (ergs),  is 
represented  by  energy  expeuded  in  one  second  by  1  ampere  in  1  ohm. 

"  (7)  Power.  —  The  Watt,  =  107  absolute  uuits  of  power  (ergs  per 
second),  is  power  of  a  current  of  1  ampere  flowing  under  a  pressure  of  1 
volt.  It  is  equal  to  one  joule  per  second,  aud  is  approximately  ^^  of 
cue  horse-power. 

u  (8)  Induction.  —  The  Henry,  —  109  absolute  units  of  induction,  is 
the  induction  in  a  circuit  wheu  the  electro  -motive  force  induced  in  this 
circuit  is  1  volt,  while  the  inducing  current  varies  at  the  rate  of  one 
ampere  per  second. 

"Seeing,  however,  that  quantities  a  million  times  as  great  as  some 
of  these,  and  a  million  times  as  small  as  some,  have  to  be  measured  l>y 
electricians,  the  prefixes  mega-  aud  micro-  are  sometimes  used  to  signify 
respectively  'one  million'  and  'one  millionth  part.'  Thus,  a  megohm  is 
a  resistance  of  one  million  ohms,  a  micro-farad  a  capacity  of  y^nr^innr  °f  a 
farad,  etc.  The  prefix  kilo-  is  used  for  '  one  thousand  '  and  milli-  for  '  one 
thousandth  part  '  ;  thus,  a  kilowatt  is  1000  watts,  and  milliampere  is  the 
thousandth  part  of  1  ampere. 

"  The  'practical'  system  may  be  regarded  as  a  system  of  units 
derived  not  from  the  fundamental  units  of  centimeter,  yrammc,  andsm»wf, 
but  from  a  system  in  which,  while  the  unit  of  time  remains  the  second, 
the  units  of  length  and  mass  are  respectively  the  earth-quadrant  aud 
10"  grammes."  ' 

C.  DEFINITIONS  AND  EQUATIONS. 

We  are  now  prepared  to  follow  our  analogy  in  the  comparison  be- 
tween the  flow  of  \\ater  in  a  tube  and  the  How  of  the  electric  current. 
Tin-  lirst  principle  to  demand  attention  is  that  of  conductivity. 

Conduct!  rill/.  —  I'pon  the  si/e  and  construction  of  a  pipe  depends  the 
amount  of  energy  required  to  propel  water  through  it.  A  pipe  that  has 

'Elementary  Lessons  in  KU-ctririty  and  Magnetism.  —  Sylvanus  Thompson. 


ELECTRICITY  A XI)  MAGNETISM.  39 

•a  smooth  inner  surface  conducts  water  more  readily  and  with  less  loss  of 
energy  than  one  whose  size  is  the  same  but  has  a  rough  inner  surface. 
Similarly  does  the  flow  of  electricity  depend  upon  the  size  and  material 
of  which  the  conducting  medium  is  composed.  Au  electric  current  Hows 
through  the  entire  cross-section  of  a  conductor,  so  that  the  resistance 
offered  is  uniform  throughout  the  material.  Different  materials  conduct 
electricity  differently,  so  that  we  speak  of  their  relative  powers  as  their 
conductivities. 

Resistance:  Ohm's  Laic. — When  forcing  water  through  a  pipe  by 
means  of  pump  pressure,  the  flowing  stream  is  proportional  to  the  pres- 
sure divided  by  the  resistance.  The  resistance  is  the  result  of  friction. 
This  applies  to  an  electric  current,  the  current  strength  being  equal  to  the 
electro-motive  force  divided  by  the  resistance  and  inversely  as  the  resist- 
ance of  the  circuit ;  in  other  words,  anything  that  makes  the  E.  M.  F. 
acting  in  the  circuit  greater  will  increase  the  current,  while  anything 
that  increases  the  resistance  (either  the  internal  resistance  in  the  source  of 
E.M.F.  itself,  or  the  resistance  of  the  external  wires  of  the  circuit)  will 
diminish  the  current.  This  is  Ohm1  s  law,  and  is  frequently  expressed  thus : 

Volt  E.  M.  F.  Electro-motive  Force 

Ampere  =    C    =    =    Current    = 

Ohm  R  Resistance. 

True  electrical  resistance  depends  upou  the  nature  of  the  metal  of  which 
the  conductor  is  composed,  the  area  or  diameter  of  its  cross-section,  its 
length,  and  lastly  upou  its  temperature.  "The  greater  the  cross-section 
of  a  conductor  the  greater  is  its  electrical  conducting  power,  and  there- 
fore the  less  is  its  resistance  ;  and  the  longer  the  wire  the  less  is  its 
conducting  power,  and  therefore  the  greater  is  its  resistance." 

The  relations  of  the  above  units  may  be  expressed  as  follows  : 

1  volt  x  1  ampere =  1  watt 

1  volt  -i-  1  ohm =  1  ampere 

1  ampere  x  1  ohm =  1  volt 

1  ampere  x  1  second  x  1  ohm =  1  joule 

1  ampere  x  1  second =  1  coulomb 

III.   Sources  of  Electrical   Energy. 

The  energy  required  for  producing  the  electric  current  may  be 
derived  from 

A.  Static  1 

B.  Galvanic 

r,    -n  t  electricity. 

C.  Dynamic 

D.  Thermal       j 

A.  STATIC  ELECTRICITY  will  be  discussed  in  the  chapter  on  the  Routgen- 
ray  apparatus. 


40 


ELECTRO-THERAPEUTICS. 


B.  THE  G  ALT  AX  ic  CURREXT. 

(a)  Primary  batteries  consist  of  n  series  of  cells  containing  a  cor- 
rosive fluid,  called  the  electrolyte,  in  which  are  two  immersed  dissimilar 
metals.  The  employment  of  the  galvanic  current,  however,  is  not  prac- 
tical in  X-ray  work,  owing  to  the  necessity  of  employing  large  numbers 
of  cells  and  the  tedious  and  unpleasant  labor  occasioned  by  their  use. 
The  most  reliable  of  these  cells  are  the  Bunsen  and  the  Daniell.  The 
latter  cell  is  recognized  as  a  standard,  the  pressure  of  one  of  the  cells 
being  equivalent  to  one  volt  (approximately).  These  cells  may  be  con- 
nected in  one  of  three  ways  : 

1.  In  series. 

2.  In  parallel. 

3.  In  groups. 

(1)  Series. — In  order  to  obtain  the  highest  E.  M.  F.  (voltage)  it  is 
necessary  to  connect  the  cells  in  ''series:"  in  other  words,  the  negative 
pole  of  the  first  cell  is  connected  with  the  positive  pole  of  the  second 
cell,  the  negative  pole  of  the  second  cell  with  the  positive  pole  of  the 
third  cell  (and  so  on),  and  the  free  negative  and  free  positive  poles  of  the 
first  and  last  cells  form  the  ends  or  terminals  of  the  "battery."  In 
such  an  arrangement  the  E.  M.  F.  resulting  is  equal  to  the  sum  of  the 
E.  M.  F.  of  the  individual  cells.  (Fig.  2.) 


FIG.  2. — Connection  of  the  cells  in  "series.'1 


(2)  Parallel. — In  order  to  obtain  increased  current  strength 
(amperage)  the  cells  are  connected  in  a  manner  known  as  the  "  parallel  " 
plan  (Fig.  3),  thus :  The  positive  poles  of  the  individual  cells,  as  well 


AMP*. 


VOUT*. 


FIG.  3.— Connection  of  the  cells  in  "parallel." 

as  the  negative,  are  connected  in  such  a  manner  as  to  form  one  pole  of 
the  battery,  positive — and  the  other  pole,  negative.  In  other  words, 
by  the  union  of  the  several  cells  in  this  manner  one  large  cell  has  been 
produced.  The  resulting  electro- motive  force  is  the  electro-motive  force 
of  one  cell  only,  while  the  resistance  equals  that  of  one  cell  divided  by 


ELECTRICITY  AXD  MAGNETISM. 


41 


the  total  number  of  cells.     The  amperage  is  equal  to  the  product  of  the 
uuinber  of  cells  by  the  amperage  of  each  individual  cell. 

(3)  Group. — In  the  u  group  ••  method  some  (Fig.  4)  cells  are  joined 
in  series  and  some  are  in  parallel.  Thus, — place  two  cells  in  one  series, 
and  the  other  two  in  another  series ;  connect  the  positive  poles  of  the 
two  groups  to  form  a  positive  pole,  and  the  negative  poles  of  the  two 


FIG.  4. — Connection  of  the  cells  in  "groups." 

groups  to  form  a  negative  pole, — the  result  of  this  arrangement  being  to 
halve  the  number  of  cells  and  thus  double  their  size. 

(b)  Accumulators,  Storage  or  Secondary  Batteries. — In  1802 
Gautherot,  after  laborious  experiments,  invented  the  storage  battery. 
This  was  improved  upon  by 
Hitter  in  1803,  but  the  great- 
est improvements  were  intro- 
duced in  1859  by  the  elabo- 
rate investigations  of  Gaston 
Plaute. 

Briefly,  the  principle  in- 
volved in  the  accumulator  is 
as  follows  :  We  pass  an  elec- 
tric current  into  a  primary 
cell,  containing  two  plates  of 
similar  metals.  For  this  pur- 
pose, lead  is  almost  univer- 
sally employed,  the  chemical 
action  from  the  current  result- 
ing in  the  production  of  the 
peroxide  of  lead  (PbO2)  on 
that  sheet  of  lead  to  which 
the  positive  pole  is  attached, 
whilst  the  negative  plate  shows 
the  formation  of  spongy  me- 
tallic lead  i  Pb).  The  charging  current  is  now  removed,  the  two  plates 
of  lead  are  united,  and  a  current  having  the  opposite  direction  is  pro- 
duced. So  long  as  this  condition  is  maintained  a  new  phenomenon  is 
observed  :  the  peroxide  of  lead  suffers  a  change,  being  reduced  to  plumbic 
oxide  (PbOj,  and  the  spongy  lead  is  changed  to  the  oxide  of  lead  through 


FIG.  5.— Diagrammatic  view  of  the  inner  construc- 
tion of  a  storage  cell.  (American  Battery  Company.) 
1,  positive  binding  post;  2,  negative  binding  post ;  3  rub- 
ber cap ;  4,  hard-rubber  vent-tube ;  5,  oak  case;  6,  com- 
pound between  rubber  jar  and  oak  case ;  7,  hard-rubber 
jar;  8,  leaden  lug  attached  to  positive  plates  ;  9,  leaden 
lug  attached  to  negative  plates ;  10,  positive  plate :  11, 
negative  plate ;  12,  sulphuric-acid  solution ;  13,  soft-rub- 
ber bands  ;  14,  hard-rubber  insulators. 


42  ELECTRO-THERAPEUTICS. 

the  process  of  oxidation,  until  the  two  plates  are  again  chemically 
identical  :  when  this  condition  is  arrived  at,  the  current  ceases.  A  very 
ingenious  construction  of  this  principle  is  shown  in  Fig.  .">. 

A  marked  improvement  over  Plant  e's  accumulator  is  the  ingenious 
invention  of  Faure.  In  1881  the  latter  scientist  perfected  his  invention 
that  is  now  so  largely  employed.  lu  the  Faure  system,  the  active 
material  is  previously  prepared  and  spread  on  a  suitable  support  or 
grid— mostly  of  lead — in  such  a  manner  that  it  is  well  retained,  which 
offers  little  electrical  resistance.  For  the  positive  plates,  use  is  made  of 
red  lead  (Pb3O4)  and  sulphuric  acid  (50#  );  for  the  negative  plates,  either 
litharge  (PbO)  and  sulphuric  acid  or  porous  lead. 

Other  advantages  to  be  gained  in  the  employment  of  the  accumulator 
are : 

1.  Its  high  E.M.F.  (2  volts  for  each  cell). 

2.  Its  compactness,  portability,  and  durability. 

The  capacity  of  an  accumulator  is  usually  expressed  in  "ampere- 
hours,"  implying  the  product  of  maximum  discharging  current  together 
with  the  length  of  time  in  hours  it  discharges.  The  capacity  will  be 
slightly  reduced  when  an  accumulator  discharges  for  a  very  short  length 
of  time  at  a  higher  rate  than  the  maximum  discharge  current;  the  capac- 
ity depending  upon  the  size,  the  number  of  plates  and  their  formation. 
For  illustration,  if  we  assume  that  a  certain  accumulator  has  a  capacity 
of  forty-eight  ampere-hours  at  the  maximum  discharge  of  eight  hours, 
then  we  may  use  the  battery  normally  at  one  charge  as  follows  : 

With  one  ampere  for 48  hours 

With  two  amperes  for 24  hours 

With  four  amperes  for 12  hours 

With  eight  amperes  for 6  hours 

The  utmost  precautions  must  be  taken  in  caring  for  accumulators  ; 
this  is  of  paramount  importance,  because  they  are  very  sensitive  to 
shocks  and  over-exertion,  and  any  bending  of  the  plates  is  liable  to  give 
rise*  to  short  circuits.  There  is  likewise  danger  of  leakage  of  acid,  break- 
ing of  glass  cells,  etc.  Another  point  to  be  remembered  is  that  the  cells 
must  be  frequently  charged  and  discharged  ;  if  this  is  neglected  the  plates 
will  rapidly  become  impaired. 

It  must  not  be  forgotten  that  the  cells  must  be  arranged  in  a 
"series." 

Sulphuric  acid  of  the  best  quality  must  always  be  used  in  diluted 
form  and  free  from  all  impurities.  The  strong  acid  should  be  diluted  with 
absolutely  pure  water  to  a  specific  gravity  of  1200  or  25  Beaum6  as  shown 
by  the  hydro  meter  at  a  temperature  of  60°  F.  In  mixing  the  electrolyte 
the  acid  must  always  be  poured  into  the  water.  The  electrolyte  should 
never  be  added  to  the  cells  until  cold. 


ELECTRICITY  AND   M  A<  INK TISM. 


43 


In  subsequent  charges  and  in  general  use,  it  is  only  necessary  to 
charge  until  the  voltage  is  2.5  per  cell  while  charging.  It  is  advisable  to 
charge  the  cells  once  a  week  until  the  voltage  per  cell  is  2.5  volts  or 
about  one-third  the  normal  charging  rate. 

When  discharging,  the  electro-motive  force  of  each  cell,  as  measured 
by  the  voltmeter,  must  not  be  allowed  to  sink  below  1.85  volts  ;  thus,  in 
the  case  of  a  6-cell  battery  11  volts  is  the  lowest  limit  for  the  discharge. 

Cells  should  never  be  permitted  to  stand  idle  if  more  than  75  per 
cent,  of  their  capacity  has  been  used. 

If  a  battery  is  to  remain  idle  for  a  long  time,  it  should  first  be  fully 
charged  and  then  given  a  recharge  enough  to  bring  it  to  a  boil,  and 
left  charged. 


T\MEOST«T 


~F    \ 

1  \ 

1   \ 

J  \ 

FIG.  C.— Diagrammatic  view,  illustrating  the  charging  of  a  battery  by  the  ammeter  and  volt-meter. 

Always  see  that  the  cells  are  well  covered  with  the  electrolyte.  If  the 
latter  has  been  spilt  or  become  partly  evaporated,  it  must  be  replaced 
with  distilled  water,  and  during  the  charging  the  top  should  be  open  so 
as  to  allow  the  escape  of  the  hydrogen  bubbles.  Avoid  unnecessary 
vibration  and  shaking  of  the  cells.  With  proper  care  the  accumulator 
should  render  good  service  for  five  to  eight  years. 

Accumulators  may  be  charged  in  any  of  the  following  five  ways : 

1.  Primary  cell. 

2.  110-volt  (direct)  current. 

3.  Alternating  current. 

4.  Bicycle  dynamo. 

5.  Thermopile. 

(1)  The  method  by  the  primary  cell  is  not  practical,  because  the  labor 
involved  is  unpleasant  and  tedious,  and  the  process  is  a  most  lengthy  one. 


44 


ELECTBO- T II I •: R A  I 'EUTICS. 


(2)  The  second  method,  or  the  use  of  the  110- volt  (direct)  current,  is 
the  most  practical  and  most  easily  available  method  in  use.  It  is  neces- 
sary in  this  method  to  find  the  correct  polarity  of  both  the  110-volt  and 
also  of  the  accumulator.  The  manner  of  determining-  the  polarity  will 
be  discussed  in  a  subsequent  chapter.  It  is  necessary  by  this  method  to 
offer  a  resistance  to  the  current,  owing  to  the  circumstance  that  the 
degree  of  voltage  is  too  great  fpr  the  accumulator.  The  means  employed 
to  effect  resistance  to  this  excess  of  current  are  either  a  group  of  lamps  or 
the  rheostat.  In  the  latter  method  the  ammeter  is  placed  in  the  path  of 
the  current,  and  the  rheostat  is  so  regulated  that  the  exact  voltage  sent 
to  the  accumulator  can  be  determined  by  the  amperage  recorded  by  the 
ammeter.  (Fig.  6.) 

The  simpler  and  cheaper  method  is  that  obtained  by  the  group  of 
lamps,  mounted  on  a  base  and  connected  in  parallel.  Each  lamp  (16 
candle-power)  is  equivalent  to  one-half  an  ampere  ;  therefore,  by  this 
method  we  can  accurately  estimate  the  resistance  required,  by  introduc- 
ing that  number  of  lamps  which  will  be  necessary  to  produce  the  proper 
amperage  for  charging  the  accumulator.  When  the  accumulator  is  not 
properly  connected,  the  lamps  burn  more  brightly  than  usual.  (Fig.  7.) 


o- 


3  4 


S.B. 


1  /    i    /    \    r    \ 


FIG.  7.— Diagrammatic  view,  illustrating  the  charging  of  a  battery  by  a  bank  of  lamps. 

(3)  The  alternating  current  presents  the  disadvantage  that,  not 
being  unidirectional  in  character,  it  requires  the  employment  of  a 
lt converter"  in  order  to  produce  a  unidirectional  current,  and  also  to 
provide  a  low  voltage  that  may  be  suitable  for  charging  an  accumulator. 


ELECTRICITY    AND   MACNKTISM.  i.-> 

(4)  Where  it  is  impossible  to  obtain  a  current,  as  on  the  battle-field, 
ingenious  use  has  been  made  of  the  bicycle,  by  employing  it  as  a  motor 
and  attaching  it  to  a  dynamo,  which  generates  the  current  for  charging 
the  accumulator.     This  clever  thought  originated  with  Major  Battersby 
in  his  memorable  Soudan  campaign,  and  the  method  has  been  success- 
fully imitated  in  South  Africa.     Other  means,  but  not  so  practical,  are 
by  water-power,  windmill,  or  by  horse-  or  man-power. 

(5)  The  fifth  and  last  method  is  by  the  use  of  the  thermopile  for 
charging  purposes,  which  has  found  but  little  favor,  and  is  rarely,  if 
ever,  employed  in  this  country. 

C.  DYNAMIC  OR  ELECTRIC  MAINS  are  of  two  kinds : 

(a)  Direct. 

(b)  Alternating. 

(a)  Continuous  or  Direct. — In  places  where  a  current  from  the 
continuous  commercial  main  is  available  and  voltage  ranges  from  100  to 
250,  advantage  is  often  taken  of  this  source  of  energy,  owing  to  the  fact 
that  it  presents  few  difficulties  and  demands  but  little  attention  ;  the 
rheostat  alone  being  necessary  to  regulate  both  the  voltage  and  amperage. 

(b)  Alternating  or  Street  Current. — When  it  is  necessary  to  em- 
ploy an  alternating  current,  there  will  be  required  a  motor-transformer. 

D.  THERMOPILES. 

In  1822  Professor  Seebeck,  of  Berlin,  accidentally  discovered  that 
when  heat  is  applied  to  a  circuit-junction,  a  current  of  electricity  is  pro- 
duced ;  also,  that  when  two  junctions  are  of  different  temperatures,  the 
current  produced  is  directed  from  the  warmer  to  the  colder  junction. 
Thermopiles  are  very  seldom  employed  for  working  an  induction  coil. 
Their  use  is  extremely  limited  in  this  country. 


CHAPTER   II 
THE  STATIC,  FRANKLLNTC,   OR  FRICTION AL  CURRENTS. 

THERE  are  three  chief  forms  of  electricity  used  iu  medicine  and 
surgery  : 

Static,  Frankliuic,  or  frictional. 

Galvanic,  continuous,  or  direct. 

Faradic,  interrupted,  or  indirect. 

The  other  so-called  varieties,  such  as  the  sinusoidal  current,  high- 
frequency  currents,  etc.,  are  modifications  of  the  above  forms. 

I.  The  Static  or  Influence  Machines. 

Ever  since  static  electricity  was  discovered  and  the  first  static 
machine  was  invented  by  Otto  von  Guericke,  a  burgomaster  of  Magde- 
burg, Germany,  in  1647,  the  subject  has  received  the  closest  study  from 
scientific  minds.  Sir  Isaac  Newton  eagerly  seized  and  improved  upon 
von  Guericke' s  discoveries,  and  these  early  researches  were  continued 
through  the  centuries  by  English,  German,  French,  and  Italian  phi- 
losophers, not  the  least  conspicuous  among  whom  may  be  cited  Ramsden, 
Plant4,  and  De  la  Fond.  While  the  friction  or  static  machines  of  these 
searching  inquirers  are  now  obsolete,  their  persistent  study  laid  the 
foundation  for  the  present-day  influence  machines. 

In  the  construction  of  influence  machines  two  important  principles 
are  carried  out  :  (1)  the  principle  of  influence,  whereby  a  conductor 
touched  acquires  a  charge  of  the  opposite  kind,  and  (2)  the  principle  of 
reciprocal  accumulation. 

"In  Fig.  8  let  us,  for  instance,  employ  two  insulated  conductors,  A 
and  B,  electrified  ever  so  little,  one  positively  and  the  other  negatively. 
Let  a  third  insulated  conductor  C,  which  we  shall  call  a  carrier,  be 
arranged  to  move  so  that  it  first  approaches  A  and  then  B,  etc. 

"If  touched  while  under  the  influence  of  the  small,  positive  charge 
on  A,  it  will  acquire  a  small  IK -gative  charge  ;  suppose  that  it  then  moves 
on.  and  gives  this  negative  charge  to  B,  and  it  then  be  touched  while 
under  the  influence  of  B,  so  acquiring  a  small  positive  charge.  When 
it  returns  toward  A,  let  it  give  up  this  positive  charge  to  A,  thereby 
increasing  its  positive  charge.  Then  A  will  act  more  powerfully,  and 
on  repeating  the  former  operations  both  B  and  A  will  become  more 
highly  charged.  Kach  accumulates  the  charges  derived  by  the  inilu- 
ence  from  the  other.  This  is  the  fundamental  action  of  all  the  modern 

46 


FRICTIOXAL  CURRENTS. 


47 


influence  machines,  dating  from  1860,  the  first  having  been  constructed 
i»y  ('.  F.  Varley,  consisting  of  six  carriers  mounted  on  a  rotating  disk  of 
glass."1 

A.  TYPES  OF  INFLUE.M  i:  MACHINES. 

(a)  The  Wimshurst  influence  machine  (Fig.  10)  consists  of  two 
circular  disks  of  glass,  so  mounted  as  to  be  rotated  in  opposite  directions, 
at  a  distance  of  one-eighth  of  an  inch  apart.  Each  disk  is  attached  to 
the  end  of  a  boss  of  ebonite,  upon  which  is  turned  a  small  pulley.  Both 
disks  are  well  varnished  and  cemented.  To  the  outer  surface  of  each  are 
twelve  or  more  sectors,  made  of  thin  brass  and  at  equal  angular  distances 
apart.  Twice  in  each  revolution,  the  two  sectors  situated  on  the  same 


FIG.  8.— Diagrammatically  illustrates  the  principle  of  influence  and  accumulation  of  static  or 

influence  machines. 

diameter  of  each, disk  are  momentarily  placed  in  metallic  connection  with 
one  another  by  a  pair  of  fine  wire  brushes,  supported  at  the  middle  of  its 
length,  by  one  of  the  projecting  ends  of  the  fixed  spindle  upon  which  the 
disks  rotate,  the  sector  plates  just  grazing  the  tips  of  the  brushes  as  they 
rotate.  The  position  of  the  two  pairs  of  brushes  with  respect  to  the  fixed 
collecting  combs  and  to  one  another  is  variable. 

The  fixed  conductors  consist  of  two  forks,  furnished  with  collecting 
combs  directed  toward  one  another  and  toward  the  two  disks  which  rotate 
between  them,  the  position  of  the  two  forks,  which  are  supported  on 
ebonite  pillars,  being  along  the  horizontal  diameter  of  the  disk.  To  these 
fixed  conductors  are  attached  the  terminal  electrodes,  whose  distance 
apart  can  be  varied.  This  form  of  machine  is  very  efficient  and  self- 
excitiiig,  provided  that  a  sufficient  number  of  sectors  be  present,  for  it  is 


56,  57. 


1  Sylvan  us  Thompson,  Elementary  Lessons  in  Electricity  and  Magnetism,  pp. 


4S 


ELECTKO-THERAPEUTICS. 


found  that  the  machine  works  at  full  power  after  the  second  or  third 
revolution  of  the  handle.  The  "NVimshurst  machine  works  best  when  the 
resistance  of  the  discharging  circuit  is  high,  and  it  has  been  proposed  to 
enclose  the  apparatus  in  a  strong  metal  case,  and  to  work  it  under  a  pres- 
sure of  several  atmospheres,  thus  avoiding  leakage  through  brushing. 

The  theory  of  action  of  these  machines  is  perhaps  best  explained  by 
the  aid  of  the  accompanying  illustration  (Fig.  9),  in  which,  for  the  sake 
of  greater  clearness,  "two  rotating  plates  are  represented  as  though  they 
were  two  cylinders  of  glass,  rotating  in  opposite  directions,  one  within  the 
other.  The  smaller  inside  cylinder,  in  the  figure,  represents  the  front 
plate,  and  the  larger  outer,  the  back  plate :  the  front  plate  rotates  right- 
handedly,  and  the  back  plate  left-haudedly.  The  neutralizing  brushes, 


FIG.  9.— Illustrates  diagrammatically  the  theory  of  action  of  a  Wimshurst  influence  machine. 

Wx,  »2,  touch  the  front  metallic  sectors,  represented  near  the  top  of  the 
diagram,  to  receive  a  slight  positive  charge.  As  it  is  moved  onward 
toward  the  left  it  will  come  opposite  the  place  where  one  of  the  front 
sectors  is  moving  past  the  brush  wt.  The  result  will  be  that  the  sector 
touched  while  under  influence  by  nl  will  acquire  a  slight  negative  charge, 
which  it  will  carry  onward  toward  the  right.  When  this  negatively 
charged  front  sector  arrives  at  a  point  opposite  n3,  it  acts  inductively  on 
the  back  sector  which  is  being  touched  by  n3 ;  hence  this  back  sector  will 
in  turn  acquire  a  positive  charge,  which  it  will  carry  over  to  the  left.  In 
this  way  all  the  sectors  become  more  and  more  highly  charged  ;  the  front 
sectors  carrying  over  negative  charges  from  left  to  right,  and  the,  back 
sectors  carrying  over  positive  charges  from  right  to  left.  At  the  lower 


FRICTIONAL  CUEEENTS. 


49 


half  of  the  diagram  a  similar  but  inverse  set  of  operations  take  place. 
For  when  %  touches  a  front  sector  under  the  influence  of  a  positive  back 
sector,  a  repelled  charge  will  travel  along  the  diagonal  conductor  to  n%, 
helping  to  charge  positively  the  sector  which  it  touches.  The  front 
sectors,  as  they  pass  from  right  to  left,  in  the  lower  half,  will  carry  posi- 
tive charges ;  while  the  back  sectors  after  touching  n4  will  carry  negative 
charges  from  left  to  right. 

"The  metal  sectors  then  act  both  as  carriers  and  inductors.     It  is 
clear  that  there  w7ill  be  a  continual  carrying  of  positive  charges  to  the 


FIG.  10.—  Wimshurst  influence  machine. 

right,  and  of  negative  charges  to  the  left.  At  these  points,  toward  which 
the  opposite  kinds  of  charges  travel,  are  placed  the  collecting  combs  com- 
municating with  the  discharging  knob."1 

(&)  Holtz  of  Berlin  invented  a  very  powerful"  influence  machine. 
(Fig.  11.)  In  brief,  it  consists  of  two  glass  plates,  the  diameter  of  one 
plate  being  slightly  larger  than  the  other.  The  plates,  though  in  close 
relationship,  do  not  touch.  The  fixed  plate  contains  two  " windows" 

1  Sylvanus  Thompson,  Elementary  Lessons  in  Electricity  and  Magnetism,  p.  63. 


50 


1 : 1 , 1  ;<JTKO-THERAPEUT  1  (  S. 


directly  opposite  one  another.  Two  bits  of  paper  (field  plates)  are  glued 
to  the  stationary  plate,  oue  above  the  window  on  the  left  side,  and  one 
below  the  window  on  the  right.  From  each  of  these  pieces  of  paper  a 
tongue  protrudes  through  each  aperture,  almost,  but  not  quite  touching 
the  revolving  plate.  The  plate  is  rotated  in  a  direction  opposite  to  that 
in  which  the  tongue  projects.  The  prime  conductor  consists  of  two 
metallic  combs,  supported  by  brass  rods  with  knobs,  and  mounted  on 
glass  supports.  Two  other  brass  knobs  with  ebonite  handles  and  knobs 
form  the  discharging  electrodes,  through  whose  agency  the  spark  length 
can  be  varied.  A  neutralizing  rod  to  minimize  the  reversal  of  polarity 


FIG.  11.—  Toepler-Holtz  influence  machine. 

is  also  provided.  Before  working  the  machine,  one  of  the  field  plates 
must  l>e  charged  from  an  outside  source  and  the  knobs  of  the  discharging 
rods  must  be  brought  together. 

(c)  The  Voss  or  ToepJfr  is  more  self-exciting  than  the  Holtz,  but  is 
less  si i re  in  its  action  than  the  WimahniBt  The  Voss  resembles  the  Jlolt/ 
machine  in  many  details,  but  the  moving  plates  carry  a  lew  sectors,  and 
these  in  their  rotation  touch  a  pair  of  brushes  carried  by  two  bent  arms 
which  connect  with  the  Held  plates,  and  so  convey  charges  from  the  mov- 
ing plate  to  the  armature  of  the  fixed  field  plates.  In  this  country  there 
are  practically  no  Wimshurst  machines  used.  They  are  nearly  all 
Toepler-Holtz  machines,  that  is  to  say,  Holtz  machines  modified  so  as  to 


FKKTIOXAL  CURRENTS.  51 

be  self-exciting,  as  invented  by  Toepler.  The  Eastern  manufacturers  are 
largely  using  the  Holt/  machines  which  are  excited  by  a  smaller  genera- 
tor of  the  Wimshurst  or  Toepler  type,  while  mostly  all  the  Western 
manufacturers  use  the  Toepler- Holtz  type  machine. 

B.  CAKE  AND  MANIPULATION  <>F  STATIC  MACHINK. 

In  the  use  of  influence  machines  certain  requisites  are  necessary  to 
insure  satisfactory  results.  Chief  among  these  are  dry  ness  and  cleauli- 
!ie>».  The  accumulation  of  dust  or  moisture  upon  the  insulating  surfaces 
interferes  with  the  high  voltage  that  must  be  obtained.  The  machine 
may  be  freed  from  dust  and  moisture  by  the  use  of  a  dry  silk  fabric; 
the  oxidation  of  the  metallic  sectors  can  be  effectively  obviated  by  cleans- 
ing them  with  a  cloth  previously  immersed  in  benzine  or  gasoline.  Alco- 
hol should  never  be  used  on  any  varnished  part,  as  it  acts  as  a  solvent 
thereof.  During  the  summer  months  when  the  air  is  often  surcharged 
with  moisture,  it  becomes  necessary  to  place  in  the  case  a  deep  tray 
containing  fused  calcium  chloride  ;  this  must  be  free  from  impurity,  else 
there  will  result  oxidation  of  the  metallic  parts.  Likewise  during  the 
torrid  season  it  is  found  that  the  current  acting  on  the  air  in  the  case  of 
the  machine,  develops  a  nitrous  oxide,  and  that  the  nitrogen  combining 
with  hydrogen  forms  nitrous  acid  accumulations,  which  are  detrimental 
to  the  working  of  the  machine.  Wagner  uses  ventilators  in  his  machine, 
which  carry  off  the  nitrous  oxides,  and  recommends  that  during  the  sum- 
mer months  a  dish  containing  oil,  such  as  boiled  linseed  oil,  be  placed. 
inside  of  the  case.  The  oil  takes  up  the  active  nitrogen  because  it  has 
more  affinity  for  the  nitrogen  than  for  the  hydrogen.  Sulphuric  acid  is 
also  one  of  the  Ix-st  and  most  inexpensive  driers  that  can  be  used  in  a 
static  machine.  When  it  is  used,  it  should  be  placed  in  a  broad,  open 
dish,  four  or  live  inches  deep,  and  the  full-strength  commercial  sulphuric 
acid  should  not  more  than  half  fill  the  dish,  as  the  acid  will  take  up  the 
moisture  and  increase  until  it  has  almost  doubled  its  volume  ;  then  it 
loses  its  efficiency  as  a  drier. 

When  used  tor  exciting  an  X-ray  tube,  this  machine  must  be  operated 
by  a  power  capable  of  giving  a  high  and  steady  electro-motive  force.  In 
cities  an  electric  motor  (of  the  required  horse-power)  should  be  em- 
ployed ;  in  country  places  water  motors  or  gasoline  engines  should 
furnish  the  power  ;  hand  power  with  this  machine  is  inefficient  for 
skiagraphy. 

The  length  of  a  spark  of  a  properly  working  machine  ought  to 
equal  the  radius  of  the  revolving  plates  (approximately).  Care  should 
be  exercised  that  the  neutralizing  brushes  are  so  bent  as  to  bring 
them  in  proper  contact  with  the  disks  during  the  whole  period  of 
revolution. 


52  ELECTKO-THERAPEUTICS. 

The  electro-motive  force  of  a  static  machine  depends  upon  the 
number  of  revolutions  per  minute,  the  size  and  number  of  the  revolving 
plates,  aud  the  general  construction  and  care  of  the  same. 

Glass  plates  have  been  in  use  for  more  than  a  century,  but  mica 
plates  possess  certain  advantages.  They  are  not  fragile  and  less  hygro- 
scopic than  glass  ones,  and  I  have  never  kuowu  them  to  warp.  Because 
of  the  non-breakable  character  of  mica,  a  high  speed  can  be  obtained  for 
the  generation  of  extremely  high  volume  of  tension  of  current. 

Machines  not  self-exciting  have  a  charge  added.  This  is  usually  fur- 
nished by  a  revolving  plate  to  which  are  fastened  several  brass  sectors. 
On  revolving,  the  latter  are  brought  into  contact  with  the  brushes.  The 
stationary  plate  of  this  machine  encloses  a  sheet  of  tin-foil  or  paper  as 
a  collector. 

A  static  machine  in  bad  order  is  said  to  have  "lost  its  charge" 
when  it  fails  to  generate  electricity.  This  may  be  caused  by  dampness, 
by  the  humidity  of  the  atmosphere,  or  by  turning  the  crank  attached  to 
the  driving-wheel  in  the  wrong  direction. 

C.  ACCESSORIES. 
THE  LEYDEX  JAR. 

This  is  an  electro-static  condenser,  so  named  from  its  invention  by 
Cuneus,  in  the  town  of  Leydeii,  in  1745.  In  its  modern  form,  a  Ley  den  jar 
is  a  cylindrical  glass  bottle,  lined  inside  and  out  with  tin  foil,  to  within 
a  short  distance  of  the  top.  A  brass  knob  inserted  in  the  wooden  cover 
is  connected  with  the  inner  coating  \)y  means  of  a  wire  or  chain. 

Thus  we  have  essentially  two  conductors,  the  one  almost  completely 
enclosed  in  the  other  and  separated  from  it  only  by  the  thickness  of  the 
dielectric.  If  either  conductor  is  put  to  earth,  and  the  other  insulated 
and  charged,  an  opposite  and  nearly  equal  charge  is  induced  in  the  former. 
Leydeu  jars  are  frequently  connected  in  series  (the  cascade  arrangement) 
to  secure  a  potential  difference  equal  to  the  sum  of  those  due  to  the  elec- 
trification of  the  individual  jars,  or  in  multiple,  all  outside  coatings  con- 
nected together  and  inner  coatings  the  same,  when  increased  quantity  is 
desired. 

ELECTRODES.     (Figs.  12  and  13.) 

These  may  be  of  metal  or  of  wood.  The  metallic  electrodes  are 
usually  of  brass,  made  in  a  variety  of  shapes  and  sizes,  and  may  be 
round,  pointed,  etc.,  each  being  mounted  upon  a  holder  of  ebonite  (vul- 
canite), which  acts  as  an  insulator.  Boilers  are  usually  made  of  brass, 
and  mounted  upon  a  base  or  stem  of  elxmite.  The  wooden  electrodes  are 
usually  described  as  discharge  electrodes,  but  they  are  not  so  frequently 


FRICTIOXAL  CUKKEXTS. 


53 


employed  as  are  the  metallic  variety.  Lately  glass  vacuum  electrodes 
lmv<-  come  iuto  vogue.  A  convenient  handle  for  holding  electrodes  is 
shown  in  Fig.  14. 


CHAIN-HOLDER. 

This  is  usually  a  brass  ring  or  hook  attached  to  an  ebonite  stem,  and 
is  employed  for  holding  the  chain  which  conducts  the  current  from  one 


54  ELK<  T I  {( )-T  I  \  ER  APEUTICS. 

pole  of  the  machine  to  the  electrode  (Fig.  l">i.     It  prevents  bringing  the 
chain  in  contact  with  the  patient,  and  thus  avoids  shock. 

MUFFLER. 

This  is  a  cylindrical  glass  tube,  into  the  ends  of  which  are  fastened 
discharge  rods.  The  tul>e  in  a  horizontal  position  is  held  to  the  discharge 
rods  of  the  static  machine  by  means  of  wire  hooks.  The  rods  of  the 
muffler  can  be  readily  adjusted  by  simply  turning  them  in  a  screw-like 
fashion.  This  is  employed  for  the  purpose  of  lessening  the  noise  from 
the  discharge  rods  of  the  static  machine. 

PREPARATION  OF  THE  PATIENT. 

When  a  patient  comes  for  treatment  it  is  necessary  to  ascertain  the 
nature  of  the  disease,  before  deciding  upon  the  kind  of  treatment  to  be 
instituted.  If  the  method  selected  requires  the  removal  of  some  of  the 
apparel,  this  should  be  arranged  by  the  physician' s  attendant  or  nurse 
in  a  separate  room.  If  much  of  the  clothing  is  removed,  a  wrapper  or 
loose  gown  should  be  thrown  over  the  patient.  If  the  patient  is  nervous 
it  is  advisable  to  instruct  the  attendant  to  remove  as  few  of  the  garments 
as  practicable,  so  as  not  to  offend  modesty  and  in  order  to  lessen  the 
fear  so  frequently  induced  by  the  careless  therapeutist.  Celluloid  combs 
and  all  hair-pins  should  be  removed  from  the  patient's  head  ;  if  hair-pins 
be  permitted  to  remain  they  may  cause  unpleasant  pricking  sensations  in 
the  scalp. 

The  patient  should  be  placed  in  a  comfortable  position  and  far 
enough  from  the  machine  to  prevent  shocks  from  the  emitted  sparks.  In 
damp  weather  or  when  the  current  is  not  very  strong  the  patient  should 
hold  the  metallic  electrode.  The  cords  leading  from  the  discharge  rods 
should  not  touch  the  ground,  the  patient,  or  each  other :  if  they  rest 
upon  the  floor  or  " ground"  there  will  be  a  flow  of  current  into  the 
earth,  if  they  touch  the  patient,  shock  will  occur,  and  if  they  touch  one 
another  a  short  circuit  will  result.  I  prefer  to  treat  the  patient  in  the 
sitting  posture,  as  this  permits  the  application  of  the  current  to  all  parts 
of  the  body,  especially  if  he  be  seated  upon  a  revolving  stool.  Occasion- 
ally it  may  l>c  necessary  to  adjust  his  chair  so  that  he  cannot  rotate  it, 
thus  allowing  a  constant  flow  of  current  to  the  part  needing  treatment. 

POLARITY. 

The  polarity  of  a  static  current  is  not  of  great  moment.  I  have 
heard  some  patients  say  that  the  current  of  the  positive  electrode  is  more 
pleasant  than  the  negative  and  others  affirm  the  opposite.  I  am  of  the 
opinion  that  there  is  little,  if  any,  difference  between  the  positive  and 


FRICTIOXAL  CURRENTS.  55 

negative  electrodes,  so  far  as  the  emanating  current  is  concerned.  Never- 
theless, this  is  easily  determined  Itv  starting  tlie  machine  with  tin-  mils 
slightly  apart,  and  obserx  in^  that  the  spark  is  whitest  near  the  posi- 
tive pole,  due  to  incandescent  oxygen  1  icing  whiter  than  incandescent 
nitrogen. 

The  positive  electrode  emits  a  sharp  hissing  noise  when  placed  in  a 
horizontal  position. 

Xo  current  will  flow  when  a  non-conductor  is  applied  to  the  negative 
discharge,  but  it  will  flow  from  the  positive. 

The  positive  pole  can  be  determined  by  the  collecting  combs  showing 
points  of  light,  while  a  brush-like  form  is  evidenced  upon  the  negative 
side.  This  is  best  observed  in  a  darkened  room  while  the  sliding  rods  are 
in  contact. 

If  we  separate  the  balls  on  the  ends  of  the  sliding  rods  for  an  interval 
of  two  centimeters,  the  spark  stream  issuing  between  the  rods  displays  a 
distinct  violet  portion,  which  begins  at  the  ball  in  a  bright  point.  This 
violet  portion  denotes  the  negative  pole,  while  the  positive  pole  is 
reciignized  by  a  bright  area  of  white  light  lying  near  it. 

To  reverse  the  polarity  of  an  influence  machine,  the  usual  procedure 
is  to  ground  both  terminals,  and  give  the  machine  a  few  turns  in  the 
opposite  direction,  then  remove  the  grounds  and  start  the  machine 
normally.  The  effect  of  this  operation  is  rather  uncertain,  and  Herr  J. 
R.  Janus/.kiewicz1  has  devised  a  system  which  is  more  reliable.  In  this 
one  pole  of  the  machine  is  connected  electrically  to  the  inducing  plate  for 
the  opposite  pole.  The  machine  is  revolved  in  the  normal  direction, 
and  if  the  connection  then  be  broken  the  polarity  of  the  machine  will  be 
found  to  be  reversed.  If  the  machine  is  running  at  a  fair  speed  only  a 
momentary  connection  is  needed,  but  if  it  is  running  slowly  it  may  be 
necessary  to  leave  the  connection  for  ten  or  fifteen  seconds.  Care  should 
be  taken  that  good  electrical  contact  is  made.  A  new  pole  changer  that 
bids  to  become  very  popular  is  shown  in  Fig.  16,  which  illustrates  the 
wrou<r  connection  of  the  Crookes  tube  with  the  static  machine,  as  is  iudi- 

0  ' 

cated  by  the  heavy  lines.  By  this  arrangement  we  correct  the  polarity 
without  changing  the  position  of  the  tube,  by  sliding  the  rod,  H,  from 
C  to  C1.  the  rod  carrying  the  positive  pole,  which  becomes  A'  (anode). 
The  negative  pole,  D,  touches  the  metal  D1,  which  is  carried,  and  becomes 
B1  (cathode). 

IDIOSYNCRASY. 

By  this  term  is  meant  the  susceptibility  of  the  patient  to  the  ac- 
tion of  the  static  electric  cm-rent.  It  has  frequently  been  observed  that 

1  Physikalische  Zeitschrift  (Leipsic),  abstracted  in  the   Electrical  Review,  Oct 
15,  1904. 


56 


ELECTKO-THERAPEUTICS. 


certain  patients  are  unusually  susceptible  to  static  electricity.  I  have 
seen  many  cases  where  a  static  breeze  applied  to  the  head  was  sufficient 
to  cause  fainting,  or  at  least  dizziness.  For  such  patients  it  is  necessary 
to  diminish  the  strength  of  the  current,  also  to  shorten  the  length  and 
lessen  the  number  of  applications. 

THE  DOSAGE. 

By  this  term  is  meant  the  length  of  time  required  for  administering 
the  current  in  the  particular  case,  the  intensity  of  each  treatment, — /.  c., 
the  strength  of  static  current  produced  and  applied, — and  the  frequency 


FIG.  16.— Pole  changer  of  Betz. 

of  its  use.  The  length  of  each  application  should  be  between  ten  :m<I 
twenty-five  minutes.  The  number  of  applications  will  naturally  depend 
upon  the  character  of  the  disease  treated,  the  suffering  of  the  patient, 
and  also  upon  idiosyncrasy.  Here  is  where  good  judgment  and  skill  on 
the  part  of  the  therapeutist  are  required.  It  is  the  general  practice  to 
give  from  one  to  five  treatments  a  week.  Frequently  the  pat  lent  inquires 
as  to  the  number  of  applications  requisite  before  a  change  in  the  disease 
will  be  noted.  Unfortunately,  we  are  not  able  to  answer  such  ques- 
tions satisfactorily.  I  have  seen  cases  where  only  three  or  five  treat- 
ments were  necessary ;  again  I  have  seen  cases  of  the  same  disease 
where  twenty  treatments  were  necessary  before  a  change  for  the  better 
could  be  observed. 


FIG.  17.— Static  breeze,  concentrated  brush  discharge,  or  spray.  If  the  crown  is  positive,  it  is  a 
contractor  of  blood-vessels  and  acts  as  an  anaesthetic.  If  it  is  negative,  it  dilates  and  liquefies  and  is  an 
irritant.  The  indicator  on  the  machine  is  turned  to  the  printed  word  "breeze." 


Fio.  18.— Static  negative  insulation  or  gtatic  bath.    Patient  holds  the  negative  electrode  on  an 
insulated  platform  ;  positive  is  grounded  and  the  sliding  electrodes  are  widely  separated. 


FIG.  19.— Direct  spark. 


Flo.  20.— Indirect  spark. 


FRICTIONAL  CURRENTS.  57 

II.   Modes  of  Application. 

The  forms  of  application  used  in  electro- therapy  are  : 
CONYKCTIVE  \ 

DlSlU'I'TIYK        DIscHAKliKS. 

CONDUCTIVE  ) 

A  «  <>NYK(TiYi;  discharge  occurs  when  electricity  of  a  high  poten- 
tial discharges  itself  at  a  pointed  conductor  by  accumulating  there 
with  a  density  sufficient  to  electrify  the  neighboring  particles  of  air 
(these  particles  then  flying  off  by  repulsion),  and  conveying  away 
with  them  part  of  the  discharge.  This  form  of  application  is  illustrated 
in  the  use  of  the  static  bath,  the  breeze,  and  the  spray  as  given  off 
from  metal  electrodes,  the  high-frequency  discharges  from  glass  vacuum 
tubes,  etc. 

The  DISRUPTIVE  discharges  embrace  the  various  sparks, — the  long, 
short,  and  frict ion. 

The  CONDUCTIVE  discharge  is  derived  from  an  electrified  conductor. 
This  may  be  a  continuous  current  flowing  through  a  thin  wire  connecting 
the  knobs  of  an  influence  machine  or  joining  the  positive  pole  of  a 
battery  to  the  negative  pole. 

A.    CoN'VKCTIVi:    CUKKKXTS. 

In  using  the  brush  discharge  (Fig.  17)  the  patient  holds  either  elec- 
trode while  the  other,  which  may  be  pointed,  broom -shaped,  or  coronal  in 
outline,  is  applied  to  the  area  to  be  treated.  This  includes  the  breeze 
and  spray  (all  these  terms  being  synonymous);  the  breeze  is  the  concen- 
trated brush  disci  large. 

The  static  bath  (Fig.  18),  also  called  static  insulation,  is  administered 
by  having  the  patient  on  an  insulated  platform  in  communication  with 
one  of  the  poles  of  the  machine  ;  after  some  turns  of  the  handle,  it  is 
found  that  he  is  charged  with  positive  electricity  of  a  high  potential, 
while  there  is  a  constant  waste  of  electricity  from  all  parts  of  his  body 
and  clothing.  The  effect  of  the  static  bath  is  ultimately  sedative  and  it 
is  the  form  usually  employed.  It  may  be  greatly  intensified  by  applying 
to  the  affected  part  a  tinsel  rosette  instead  of  a  crown  piece.  Strong 
revulsive  effects,  leading  to  actual  blistering,  may  occur  when  the  patient 
is  connected  directly  with  the  positive  pole.  Dr.  G.  Bettou  Massey,  who 
has  had  a  great  deal  of  experience  in  electro-therapeutics,  believes  that 
this  intensified  spray  has  a  deep  penetrating  action  and  is  of  great  value 
in  intractable  chronic  rheumatism. 

In  the  interrupted  insulation  the  negative  electrode  is  held  by  the 
patient  and  the  positive  is  grounded.  The  sliding  electrodes  are  moved 
to  and  fro,  so  as  to  produce  an  interruption  in  the  current. 


58  ELECTKO-TIIEK  APEUTI CS. 

B.  DISRUPTIVE  CURRENTS. 

These  are  subdivided  into  the  direct,  indirect,  and  friction. 

In  the  direct  <Iix/- a j>f ire  current  (Fig.  ID)  the  patient  is  seated  oil  the 
platform,  holding  either  the  positive  or  the  negative  electrode,  the 
remaining  electrode  l>eing  applied  to  the  affected  part.  The  Leyden  jar 
may  or  may  not  be  in  the  connection.  When  it  is  so  connected,  the  cur- 
rent, as  a  rule,  is  usually  too  severe.  The  spark-gap  is  wide  open. 

Direct  sparks  are  very  painful,  and  are  to  be  used  only  in  cases  of 
surface  anaesthesia. 

The  indirect  disruptive  current  differs  from  the  above  in  that  the  pa- 
tient sits  on  the  platform,  holding  the  negative  electrode,  the  positive 
being  grounded.  If  the  electrode  chain  is  attached  to  the  water-pipe 
(the  indifferent  pole  being  attached  to  the  gas-pipe),  more  capacity  is 
gained,  the  single  sparks  give  good  muscle  responses  with  little  pain. 
(Fig.  20.) 

The  friction  disruptive  current  differs  from  the  indirect  only  in  that  the 
roller  electrode  is  rapidly  applied  against  the  affected  part.  (Fig.  21. ) 

C.  CONDUCTIVE  CURRENTS. 

Conductive  currents  are  subdivided  into  the  static  induced  current 
and  the  wave  current. 

The  static  induced  current  (Fig.  22)  is  in  connection  with  both  the 
Leyden  jars  and  the  patient ;  the  electrodes  must  be  of  metal  and  applied 
to  the  bare  skin  or  mucous  membrane.  The  spark-gap  is  closed  at  first, 
and  then  gradually  opened  to  the  point  of  toleration. 

In  the  wave  current  the  positive  electrode  is  grasped  by  the  patient 
and  the  negative  is  applied  to  the  ground;  the  necessary  electrode  is 
block-tin  or  metallic  cloth  placed  on  the  hare  skin  or  mucous  membrane. 
Begin  the  application  with  the  discharge  rods  touching  ;  then  gradually 
separate  them  until  the  desired  strength  of  charge  is  attained. 

The  electric  souffle  or  wind  is  applied  by  directing  the  point  of  a  me- 
tallic uninsulated  rod  toward,  but  one  foot  away  from  the  patient.  The 
point  is  electrified  negatively, — L  e.,  if  we  are  using  positive  electricity. 
The  surrounding  air  particles,  becoming  electrified,  are  attracted  to  the 
nearest  part  of  the  patient's  body,  the  stream  of  molecules  producing 
a  perceptible  current  of  air.  The  action  of  the  soutlle  is  sedative. 

Dr.  William  J.  Morton's  "Wave  Current  and  High-Frequency  Ap- 
paratus"1 is  described  as  follows  : 

"One  prime  conductor  of  the  static  generator  is  grounded;  the 
other  is  connected  with  an  electrode  applied  to  the  patient  who  is  on  an 

1  Bulletin  Officiel  de  la  Soci6te  Francaise  d'Electrotherapie,  Jan.,  1899  ;  Electrical 
Engineer,  vol.  xxvii.,  March  2,  1899. 


FIG.  21.— Friction  spark  treatment. 


FIG.  22.— Static  Induced  current.  In  this  form  of  static  treatment  the  indicator  is  turned  to  the 
word  "induced,"  which  connects  the  Lcyden  jars.  The  cords  are  attached  to  the  binding  posts,  and 
the  sliding  electrodes  are  very  gradually  separated,  as  otherwise  the  shock  would  be  too  intense. 


FEICTIOXAL  (TKIiKXTS.  .V.» 

insulating  stand.  The  current  received  by  the  patient  is  due  to  the 
spark  discharge  between  the  knobs  of  the  prime  conductors.  The  patient 
forms  one  coating  of  a  Leydeu  jar  condenser,  the  other  coating  of  which 
is  the  earth  and  surrounding  objects  and  walls  connected  electrically 
therewith. 

11 '  The  greater  part  of  the  charge  and  resulting  strain  on  the  dielectric 
(air)  will  be  found  at  those  parts  of  the  patient  and  the  floor  or  walls  of 
the  room  that  are  nearest  together. 

li  If  the  spark-gap  be  long,  the  time  of  charging  by  the  small  con- 
tinuous current  will  also  be  comparatively  long,  because  the  potential 
must  be  raised  to  a  high  point  in  order  to  produce  a  long  spark.  The 
duration  of  the  discharge,  which  will  probably  be  an  oscillatory  one  of 
relatively  high  frequency  because  of  the  small  capacity  of  the  condenser, 
will  be  short.  The  small  continuous  charging  current  will  flow  through 
the  patient  without  causing  appreciable  sensation.  The  sudden  oscilla- 
tory discharge  may  flow  over  the  surface  of  the  patient  because  of  its 
high  frequency,  and  therefore  without  disagreeable  eifect.  As  the  length 
of  the  spark  gap  is  diminished,  the  time  and  amount  of  charge  become 
less,  with  a  resulting  diminution  of  sensation." 

The  following  chart  illustrates  static  modalities  in  a  convenient 
form  : 


STATIC 
Compiled  and  Arranged  by 


CLASS.               NAME. 

CONNECTIONS  FOR  POLES  LEYDKN 
AND  ELECTRODES.           JARS. 

PatCnl       *S»SSl 

SPARK- 
GAP. 

Closed  to 

Static  induced. 

Both  to  Levden  jars,  and       v 
both  to  patient. 

Metal,   to   bare 
No        skin  or  to   mu- 
cous membrane. 

begin  and 
gradually 
open     to 
tolerance 

of  patient. 

Con- 

ductive. 

Block  tin  or  rne- 

The    wave    cur-  Positive  to  patient, 
rent.                    Negative  to  ground. 

No 

Yes 

tallic   cloth    to  A    .           . 
bare    skin     or 
mucous    mem-      Induced. 

• 

brane. 

Disruptive. 

Sparks  : 
Indirect  and 
friction. 

Positive  to  patient  or  to 
platform. 
Negative  to  ground. 
Electrode  to  ground. 

Optional, 
out  as  a 
rule  too 
severe. 

Yes 

Brass 
balls. 

Wide 
open. 

connective.  Brush  discharge. 

Positive  to  ground. 
Negative  to  patient  or  to 
platform. 
Electrode  to  ground. 

No 

Yes 

Made  of  wood  of 
various  sizes 
and  shapes. 

Wide 
open. 

Breeze  and  spray 

Positive    to    patient    or 
platform. 
Negative  to  ground. 
Electrode  to  ground. 

No 

Yes 

Usually    brass 
point,  single  or 
multiple.crown 
or  broom. 

Wide 
open. 

High  -  frequency. 

Positive  to  ground. 
Negative  to  electrode. 

No 

No 

Special  glass 
vacuum. 

Begin  %"- 
gradually 
regulate  to 
capacity 

of  patient. 

Both  to  series  interrupter; 

High  -  frequency 
specially  inter- 
rupted. 

and 
negative  current  to  elec- 
trode. 

Yes 

No 

As  ordinary  h.  f. 

Wide 
open. 

Positive  to  ground. 

Water,  block  tin. 

Wide 

Con- 
vectlve. 

Potential 
alternation. 

Positive  to  patient. 
Negative  to  ground. 

No 

Yes 

wooden  or  brass, 
depending  upon 

open 
(see  re- 

work  required. 

inarksi. 

Usuallv  positive   to   pa- 

tient or  platform. 

Negative  to  ground. 

NOTE.  —  These   are    the 

The    static    bath 
or      general 
electrification. 

usual  connections.     It 
sometimes    happens 
that   the  reverse  may 
suit    certain    cases. 

No 

Yes 

None. 

Wide 
open. 

This  does  not  apply  to 

the    high-  frequency 

currents,  where  the 

connections    cannot 

be  changed. 

MODALITIES 

F.  HOWARD  HUMPHRIS,   M.D..   F.R.C.P. 


PHYSIOLOGY  AND  THERA- 
PEUTICS—(after  Sn<".\   . 


SPECIAL  INDICATIONS. 


REMARKS. 


SUBJECTIVE. 

o    Induces  muscular  contraction. 

5.  Physiological  tetanus. 

c.  Local  vibratory  effect.  Obstinate  constipation. 

CLINICAL.  Painful  neuroses. 

a.  Relieves  local  pain. 

b.  Relieves  local  congestion. 

c.  Increases  secretion. 


The  constitutional  effects  of  this 
current  are  practically  nil. 


During  the  application  of  this  cur- 
rent to  extra-sensitive  areas,  e.g. 
forehead,  eye,  ear,  nose,  and 
throat,  it  is  advisable  to  do  away 
with  the  negative  grounding. 

The  two  formsof  the  intensification 
of  this  current  have  been  omit- 
ted ;  they  are  more  local  and  less 
constitutional  in  their  effect 
when  this  (the  unmodified)  can- 
not be  used,  then  the  static  in- 
duced current  is  indicated. 


SUBJECTIVE. 

u.  Local  vibratory  effect. 

6.  Induces  muscular  contraction. 

e.  Physiological  tetanus. 
CLINICAL. 

«.  Diminishes  local  swelling  and 
congestion. 

6.  Local  pain  relieved. 

c.  Acute  muscular  spasm  relieved. 

d.  Increase  of  local    metabolism. 


Insomnia,  facial  neuralgia, 
gout,  sprains,  asthma,  rheu- 
matism, pelvic  congestion, 
lumbago,  dysmenorrhoja.  ini- 
potency,  prostatitis.  dys- 
pepsia "i  nervous),  gleet,  con- 
stipation, goitre. 


SUBJECTIVE. 

a.  stinging  sensation. 

b.  Muscular  contraction. 

c.  Blanching,  followed  by  redness, 

wheals,  and  even  blisters,  by 
successive  applications. 

d.  Increase  of  local  secretion. 
CLINICAL. 

a.  Relaxation  of  muscular  spasm. 

b.  Relief  of  pain. 

c.  Hyperaemia  and   swelling  less- 

ened. 


M  u  s  c  u  1  a  r,  subacute  and 
chronic  rheumatism,  loco- 
motor  ataxia,  rheumatoid 
arthritis,  all  deep-seated 
nervous  structural  lesions, 
and  deep-seated  pain,  sci- 
atica. Of  all  local  currents 
the  spark  is  ihe  best  dia- 
phoretic. 


SUBJECTIVE. 

a.  Increases  local  secretion. 

6.  Rubefacient,  if  pushed. 

c.  Local  antisepsis. 
CLINICAL. 

a.  Relieves  local  congestion. 

b.  Lessens  local  swelling. 

c.  Diminishes  local  pain. 

d.  Promotes  local  metabolism. 

e.  Destroys  superficial  septic  pro- 

cesses. 


The  same  as  the  brush  discharge, 
but  more  irritating  and  less  effec- 
tive. 


Early  acute  rheumatism, 
sprains,  abscess,  swelling  in 
fractures,  early  stages  in  any 
ncute  inflammation,  lum- 
bago, gout,  otitis  media, 
lupus,  tubercle,  and  any  con- 
gestion or  stasis,  with  or 
without  germ  life. 


There  is  also  the  direct  spark  ;  it  is 
very  severe  and  only  of  use  in 
humid  weather.  In  other  re- 
spects it  resembles  the  ordinary 
spark,  but  the  positive  connec- 
tion is  to  the  patient  and  the 
negative  to  the  electrode. 

The  currents  in  order  of  preference 
for  the  relief  of  pain: 

1.  Wave.         5.  Breeze. 

2.  Brush.        6.  Spray. 

3.  High-fre-  7.  Static  bath. 

quency.  8.  Static  induced. 

4.  Sparks. 


The  positive  breeze  is  stimulating, 
the  negative  is  sedative.  .  .  . 
The  negative  breeze  is  where  the 
negative  pole  and  the  electrode 
are  both  grounded  and  the  posi- 
tive pole  is  connected  with  the 
patient. 


Increase  voice  range.  Piles, 
rectal  ulcer,  fissure.  Ton- 
sillitis, catarrh,  hay  fever. 
Lupus,  acne,  and  other  skin 
affections. 

Ozone  evolved  .  .  .  Vacuum  elec- 
trodes without  wire  are  preferable, 
because  they  are  less  liable  to 
puncture,  cheaper,  and  equally 
efficient. 

The  same  as  for  the  ordinary 
high-frequency  current. 

Even  more  ozone  is  evolved.  Note 
that  the  positive  current  comes 
from  thatLeyden  jar  attached  to 
the  negative  prime  conductor, 
and  vice  versa. 

Painless,  simple,  and  fairly 
effective.  The  indications 
are  the  same  as  for  the  spark. 

Note  that  the  interruption  is  effec- 
ted w  ith  the  stand  ball  electrode 
and  the  prime  cond  uc  tor  to 
which  the  patient  is  connected. 

ALL  STATIC  MODALITIES  : 
Circulatory  System. 

a.  Lesse'n  arterial  tension. 

b.  Lessen  heart  frequency. 

c.  Lengthen  diastole. 

d.  Increase  pulse  volume. 
Ri.<piratt>rii  System. 

a.  Rapid  and   labored  breathing  Where   a  general   sedative  is 
relieved.  indicated.    Congestive  head- 

6.  Deepened   breathing,   with   in-      ache.    As  a  prelude  to,  or  in 
crease  in  elimination  of  CO2.      conjunction  with,  other 
yfrwius  System,  static  modalities. 

o.  Relieve  irritability. 
6.  Induce  soporific  effect. 
Vase-motor  System, 
a.  Induce  diaphoresis. 
6.  Induce  diuresis,  with  increased 

elimination  of  urea. 
Increase  general  metabolism.  


61 


CHAPTER   III. 
GALVANIC,  CONTINUOUS,  OE  DIEECT  CUEEENT. 

GALVANISM  is  named  in  honor  of  Galvani,  a  physician  of  Bologna, 
who  in  1790  observed  that  convulsive  seizures  could  be  produced  in  the 
limbs  of  a  dead  frog,  when  certain  metals  were  made  to  touch  the  nerve 
and  muscle  simultaneously.  The  electrical  theory  of  these  motions,  how- 
ever, originated  with  Volta,  and,  deserving  of  the  credit  that  his  genius 
gave  to  science,  his  name  is  inseparably  linked  with  the  subject  of 
galvanism. 

BATTERY. 

A  galvanic  battery  is  a  collection  of  two  or  more  galvanic  cells  (  Fig. 
23)  so  connected  that  the  electricity  generated  by  all  can  be  conducted 

X.      POS/T/  VE 

POLE 


FIG.  23.— Galvanic  cell. 

through  a  single  wire.  A  cell  consists  of  two  dissimilar  metals,  one  of 
which  is  more  readily  acted  upon  by  the  electrolyte  than  the  other. 
The  metals  usually  selected  are  zinc  and  copper.  Such  a  cell  is  frequently 
referred  to  as  a  galvanic  couple. 

CONNECTIONS. 

Upon  joining  the  two  metals  with  a  wire  an  electrical  circuit  is 
formed.  If  a  number  of  such  simple  cells  are  united  in  "series,"  the 
zinc  plate  of  one  joined  to  the  copper  plate  of  the  next,  and  so  on,  a 
greater  difference  of  potential  will  be  produced  between-  the  copper 
"pole"  at  one  end  of  the  series  and  the  zinc  "pole"  at  the  other, 
62 


DIKECT  CURRENT. 


Hence,  when  two  or  more  poles  are  connected  by  a  wire,  there  will  be  a 
greater  How  of  electricity  than  would  be  generated  by  a  single  cell.  Such 
is  the  principle  of  the  galvanic  battery.  The  connection  of  zinc  to  copper 
throughout  the  cells  makes  the  latter  in  "  series."  By  this  arrangement 
the  amperage  is  the  same  as  for  a  single  cell,  but  there  is  a  great  increase 
of  voltage. 

The  cells  are  said  to  be  in  ••parallel"  when  all  the  zincs  are  con- 
necied  with  each  other  and  all  the  coppers  are  united  to  each  other.  In 
this  instance  the  electro-motive  force  is  not  increased,  but  the  strength  of 
the  current  is  materially  augmented. 

TYPES  OF  CELLS. 

The  cells  used  in  the  formation  of  batteries  may  be  either  "  dry  "  or 
••\\et."  By  a  "dry"  cell  is  meant  the  combination  of  certain  metallic 
bodies  in  such  a  way  as  to  produce  a  simple  galvanic  current  without 
making  use  of  an  electrolyte ;  the  latter,  however,  is  employed  in  the 
••wet  "  cell.  Of  these  the  best  is  the  zinc-carbon  type,  of  which  there 
are  a  variety  on  the  market. 

Grove's  (\-U. — This  consists  of  an  outer  cell  of  glazed  ware  con- 
taining an  amalgamated  zinc  plate  and  dilute  sulphuric  acid.  In  the 
inner  porous  cell,  a  strip  of  platinum  serves  as  a  negative  pole  and  dips 
into  the  strongest  nitric  acid.  The  hydrogen  generated  bj~  the  sulphuric 
acid  acts  upon  the  zinc  and  transferred  to  the  platinum  element  meets 
the  nitric  acid  and  decomposes  it.  The  platinum  is  not  acted  upon  by 
the  acid.  The  advantage  of  the  Grove  cell  is  its  lowest  internal  resist- 
ance, and  its  high  electro-motive  force. 

Lately  the  use  of  dry  cells  has  come  into  vogue.     These  are  port- 
able, do  not  need  attention  as  to  refilling,  etc.,  and  they  are  in  every 
way  equal  to  the  best  of  the   wet    batter- 
ies.    Most    of  them  are  made  of  chloride 
of  silver,    and  are  encased    in   a   readily 
portable  box. 

The  Bioiscn  cell  (Fig.  24)  differs  from 
the  Grove's  cell  only  in  that  it  contains  a 
carbon  cylinder  in  place  of  a  platinum  plate. 
A  common  Bunseu  cell  will  give  a  current 
strength  on  short  circuit  of  12  amperes. 

To  avoid  the  annoyance  and  the  dan- 
ger occasioned  by  the  liberation  of  nitrous 
acid  fumes  derived  from  the  nitric  acid 

employed,  chromic  acid  or  a  combination  of  potassium  bichromate  and 
sulphuric  acid  may  be  substituted.  This  constitutes  the  bichromate  cell. 
This  cell  is  capable  of  generating  a  high  electro-motive  force. 


FIG.  24.—  Bunsen  cell  (double  fluid). 


64  ELECTRO-THERAPEUTICS. 

The  Leclanche  cell  consists  of  a  porous  cup  and  a  carbon  plate.  The 
positive  element  consists  of  a  rod  of  zinc,  having  a  copper  win*  attached. 
The  exciting  fluid  is  a  solution  of  sal  ammoniac,  in  which  the  zinc  dis- 
solves, forming  a  double  chloride  of  zinc  and  ammonia  ;  while  ammonia 
gas  and  hydrogen  are  liberated  at  the  carbon  pole. 

CARE  OF  THE  BATTERY. 

When  a  battery  is  frequently  and  continuously  used,  it  is  essential 
that  the  plates  should  be  kept  clean  by  washing,  scraping,  etc.  The 
solution  must  be  renewed  from  time  to  time,  and  the  zincs  must  also  be 
amalgamated. 

When  not  in  use,  the  metal  plates  should  be  withdrawn  from  the 
solution.  If  they  remain  too  long  a  time,  a  deposit  of  salt  occurs  on  the 
top  of  the  zincs,  which  must  be  removed  to  insure  the  correct  working 
of  the  apparatus.  The  battery  is  working  correctly  when  bubbles  of 
hydrogen  are  perceived  to  rise  at  the  sides  of  the  zinc. 

CHARGING  THE  CELLS. 

Dissolve  one  and  one-half  ounces  of  bichromate  of  potash  in  ten 
ounces  of  cold  water,  and  add  one  ounce  of  sulphuric  acid.  Allow  the 
solution  to  cool. 

POLARITY. 

When  a  battery  has  been  disconnected  and  put  together  again,  espe- 
cially if  it  has  many  complex  parts,  there  is  danger  that  the  positive  pole 
may  be  accidentally  connected  to  the  binding  screw  marked  " negative,'' 
and  vice  versa.  To  obviate  this  error  it  is  necessary  to  resort  to  sonic 
method  of  testing  the  polarity  of  the  electrodes.  For  this  purpose  the 
use  of  wet  litmus  answers  admirably.  The  ends  of  the  wires  resting  on 
the  litmus  for  a  few  minutes  will  show  the  results  of  electrolysis,  the 
paper  becoming  reddened  by  the  acid  liberated  at  the  positive  pole,  and 
will  turn  blue  at  the  cathode  or  negative  pole.  Other  reagents  proposed 
include  a  solution  of  phenol-phthaleiu  in  dilute  alcohol,  which  gives  ;i 
purple-red  color  at  the  cathode. 

A  quickly  performed  test,  is  to  immerse  the  tips  of  the  wires  in  a 
saline  solution,  and  it  will  be  found  that  the  negative  pole  will  give  off 
double  the  volume  of  hydrogen  gas  in  comparison  with  the  oxygen  gas 
liberated  at  the  anode. 

WALL  CABINET.    (Fig.  25.) 

This  is  of  great  utility!  in  that  it  allows  of  a  wide  range  and  varia- 
tion of  current.  It  is  so  constructed  as  to  be  readily  adapted  for  use  with 


DIRECT  riKRKXT.  65 

the  110-volt  current,  with  any  commercial  current,  or  with  a  series  of 
cells.      It  combines  a  galvanic,  faradic,  and  sinusoidal  out  Hi. 

Direct  commercial  currents  are  often  used  instead  of  cells,  but  when 
a  commercial  current  is  used  the  means  of  regulating  the  voltage  is  of 


FIG.  25.—  Wall  cabinet  for  galvanic,  faradic,  and  sinusoidal  currents. 

the  utmost  importance,  because  when  the  current  passes  through  the 
tissues  at  low  pressure  or  voltage,  there  is  more  diffusion,  and  the 
action  of  the  current  is  more  completely  confined  to  the  surface  of  the 
electrodes,  and  is  thus  less  painful ;  whereas,  when  the  current  passes 
through  the  tissues  at  high  pressure  (as  is  the  case  when  a  rheostat 

5 


66  ELECTRO-THERAPEUTICS. 

is  used  for  regulating  the  strength),  it  does  not  spread  out  in  passing 
through  the  tissues,  aud  is  thus  more  paiuful,  but  better  adapted  for 
cataphoresis. 

THE  RHEOSTAT. 

The  rheostat  or  current  controller  is  an  appliance  for  the  reduction 
of  the  known  electro- motive  force.  By  its  use  we  may  also  turn  "on?5 
or  "off"  the  current-supply  as  gradually  as  desired.  The  various  forms 
of  rheostats  have  been  fully  described. 

ELECTRODES. 

These  are  of  various  forms  aud  sizes,  as  the  special  part  and  purpose 
may  demand.  Some  of  the  most  useful  electrodes  are  those  that  are  ad- 
justable. The  latter  are  used  in  central  galvanization,  galvanization  of 
the  cervical  sympathetic,  etc.  The  adjustable  electrode  can  be  readily 
passed  under  the  clothing,  thus  obviating  the  necessity  of  the  patient  un- 
dressing. Electrodes  are  made  of  various  substances,  sponge  or  absorbent 
cotton  being  most  commonly  employed. 

The  part  to  which  the  electrodes  are  to  be  applied  must  be  free  of  all 
clothing.  If  the  skin  is  harsh,  dry,  or  hairy,  it  is  well  to  moisten  it 
with  a  sponge  dipped  in  an  aqueous  solution  of  bicarbonate  of  soda.  In 
beginning  treatment,  the  strength  of  the  current  used  should  be  regulated 
by  the  sensations  experienced  by  the  patient.  A  safe  rule  is  to  begin 
with  a  weak  current  and  gradually  increase  it.  It  is  necessary  that  the 
sponge  attached  to  the  electrode  be  frequently  washed  in  warm  water. 
and  those  that  are  much  in  use  should  be  subjected  to  the  disinfecting 
action  of  chlorinated  solutions. 

GALVANOMETER. 

This  is  an  instrument  employed  for  the  purpose  of  indicating  and 
measuring  the  strength  and  the  direction  of  a  current.  The  principle 
involved  in  its  construction  is  that  a  current  of  electricity  will  deflect  a 
magnet  from  its  normal  position.  An  ingenious  device  is  the  Deprez- 
D'Arsonval  galvanometer.  This  electrode  bears  a  inilliampereineter  and 
allows  of  application  in  any  position.  (Fig.  26. ) 

MlLLIAMPEREMETER. 

This  instrument  is  the  standard  for  measurement  of  electrical  units. 
Under  the  principles  of  electricity  we  observed  that  the  ampere  was  the 
unit  of  current  strength,  but  this  is  entirely  too  powerful  for  electro- thera- 
peutic purposes.  The  resistance  of  the  human  body  is  approximately 
3000  ohms,  and  the  milliampere  (the  one-thousandth  part  of  an  ampere) 
has  been  found  a  more  convenient  unit  for  that  resistance. 


DIRECT  CURRENT. 


67 


Tin;  GALVANO-FARADIC  Box. 

This  is  a  combination  of  the  galvanic  and  faradic  battery.  The  cur- 
rent from  the  battery  is  generated  by  tin-  Leclanclie  cell,  which  contains 
dry  sal  ammoniac,  the  necessary  water  l»eing  added  when  called  into 
use.  It  possesses  a  great  variety  of  combinations  of  length  of  wire, 
enabling  the  operator  to  regulate  the 
current  strength  at  will.  The  apparatus 
is  provided  with  a  rheostat,  a  rapid 
interrupter,  a  pole  changer,  a  slow  auto- 
matic interrupter,  etc. 

DEFINITIONS  OF  TERMS. 

Although  many  of  these  terms  have 
been  and  will  be  defined  at  length,  it 
is  thought  l>est  to  tabulate  them  here, 
so  as  to  present  in  a  compact  form  the 
commoner  expressions  employed  in 
electro-therapeutics. 

In  stabile  applications  both  elec- 
trodes are  kept  in  a  fixed  position. 

In  labile  applications  one  of  the  elec- 
trodes  is  moved  over  the  surface,  some- 
times both  are  moved  simultaneously. 

A  current  is  sometimes  called  con- 
tinuous when  it  is  allowed  to  flow  in  one 
direction,  without  interruption. 

A  current  is  said  to  be  interrupted 
when  it  is  broken  by  the  removal  of  one  of  the  electrodes,  or  by  some 
form  of  current-breaker  in  the  electrode,  or  by  any  method  of  breaking 
in  the  circuit. 

Voltaic  alternatives  is  the  term  applied  to  those  applications  in 
which  the  current  is  reversed  continually,  while  the  electrodes  are  kept 
firm. 

The  ascending  current  is  one  where  the  flow  is  from  the  periphery 
toward  the  nerve  centre. 

In  the  descending  current  the  flow  is  in  the  direction  from  the  nerve 
centre,  toward  the  periphery  of  a  part. 

By  the  term  dosage  we  mean  the  amperage  of  the  current  employed 
either  in  treatment  or  for  diagnostic  purposes  ;  the  duration  of  each  ap- 
plication of  the  electrodes,  the  amount  of  pressure  exerted,  and  the  size 
of  the  surface  of  the  electrode  applied,  are  conditions  which  must  be 
taken  into  consideration  when  the  dosage  is  to  be  accurately  ascertained. 
(Modified  after  Rockwell.) 


FIG.  26.— Deprez-D'Arsonval  galvanometer. 
(Milliamperemeter.) 


68  ELECTRO-THERAPEUTICS. 

METHODS  OF  APPLICATION. 

There  are  two  methods  of  applying  current  to  a  part, — (1) 
and  (2)  labile. 

(1)  By  the  stabile  method  we  mean  the  keeping  of  the  electrodes 
on  spots  first  ascertained,  without  moving  them  about  in   any  direc- 
tion,— i.  «.,  the  electrodes  are   retained  in  stationary   positions.     Alter 
ascertaining   the   polarity,    the   sponges    are   carefully   moistened,    and 
it  is  then  decided  which  pole  is  to  be  applied.     After  this  has  been 
done  the  electrode  is  gently  applied  to  the  part,  bearing  upon  it  with  a 
slight  degree  of  pressure.     The  current  is  now  turned  on,   beginning 
with  a  minimum   degree   of  current,   and  gradually   increasing  it  by 
turning   the  lever  of  the  rheostat ;  the  amount  of  current  applied  de- 
pending upon  the    susceptibility   of  the   patient.     The   current  should 
not  be  turned  off  suddenly,  as  this  is  liable  to  shock  and  induce  fear  in 
the  mind  of  the  patient. 

The  sudden  reversal  of  the  polarity  in  the  circuit  formed,  is  also 
liable  to  produce  an  unpleasant  sensation.  Each  and  every  apparatus 
has  certain  appliances  and  methods  of  working  them,  and  the  directions 
accompanying  the  instrument,  as  outlined  by  the  manufacturer,  should  be 
carefully  followed. 

(2)  Labile. — This  method  consists  in  keeping  one  of  the  electrodes 
at  a  certain  indifferent  part,  while  the  other  electrode  is  slowly  moved  or 
stroked  over  the  skin  of  the  part  to  which  the  current  is  to  be  applied. 
In  this  stroking,  a  certain,  even,  constant  pressure  should  be  exerted. 
As  in  the  former  instance  the  current  strength  should  be  very  gradually 
increased,  and  at  its  completion  the  current  intensity  should  again  be  re- 
duced as  much  as  possible  before  removing  the  electrode.     This  method 
has  a  stimulating  effect,  especially  upon  the  nervo-muscular  tissue  of 
the  part. 

The  positive  electrode  is  preferably  held  stationary  at  some  indif- 
ferent part,  as  in  the  right  hand  when  treating  the  lower  extremity. 
The  cathode  or  negative  electrode  is  applied  and  reapplied  alternately. 
When  contact  is  made,  a  complete  electrical  circuit  results;  when  with- 
drawn, this  circuit  is  broken,  and  no  sensation  of  a  current  can  be  felt 
by  the  patient. 

A  method  which  I  prefer  consists  of  an  interrupting  electrode 
handle.  By  pressing  a  small  lever  and  again  releasing  it,  the  circuit  is 
respectively  made  and  broken.  It  is  easy  to  manipulate,  and  the  results 
obtained  are  most  satisfactory. 

Another  method  used  is  called  the  il  voltaic  alternative,"  which  con- 
sists in  alternately  reversing  the  polarity  of  the  circuit  by  working  the 
lever  of  the  commutator  or  pole  discharger.  This  current  is  employed 
for  diagnostic  purposes,  as  in  atrophy  of  muscles  of  a  part,  etc. 


DIRECT  CURRENT.  69 

CENTRAL  GALVANIZATION. 

The  object  of  central  galvanization  is  to  subject  the  whole  central 
nervous  system  to  the  influence  of  the  galvanic  current.  One  pole,  prefer- 
ably the  cathode,  is  applied  against  the  epigastrium,  whilst  the  anode 
is  placed  over  the  forehead  for  a  period  of  time,  depending  upon  the 
purpose  for  which  the  current  is  employed.  As  a  rule,  an  application 
of  five  minutes  duration  may  be  accepted  as  a  maximum.  The  positive 
pole  should  then  be  moved  to  the  vertex,  and  thence  along  the  course  of 
the  vagus  and  over  the  sympathetic  area  to  the  lowest  extremity  of  the 
vertebral  column.  There  may  be  found  on  the  market  a  variety  of 
portable  batteries  combining  in  one  a  galvanic,  faradic,  cautery,  and 
diagnostic  lamp  battery.  (Fig.  27.) 


FIG.  27.— Galvanic,  faradic,  cautery,  and  diagnostic  lamp  battery. 

( ;  \  LVANO-FARADIZATION. 

By  this  term  we  mean  the  combination  of  both  the  galvanic  and  the 
faradic  currents.  This  may  be  applied  by  employing  four  separate  elec- 
trodes, or  by  connecting  the  secondary  coil  and  the  galvanic  battery  in 
one  circuit,  the  negative  pole  of  the  one  with  the  positive  of  the  other, 
attaching  the  electrodes  to  the  two  extreme  poles,  and  thus  passing 
simultaneously  both  currents  through  the  body. 

CAUTERY  BATTER  IKS. 

These  are  somewhat  different  from  the  batteries  above  referred  to. 
They  are  subdivided  into  two  classes, — the  thermo- cautery  and  the  light 


70  ELECTRO-THERAPEUTICS. 

battery.  It  is  here  our  aim  to  increase  the  amperage  and  not  the  electro- 
motive force,  heuce  it  is  necessai y  that  the  cells  be  arranged  in  the  form 
of  "parallels."  For  lighting  a  small  incandescent  lamp  which  requires 
a  voltage  of  6  c.  p.,  the  cells  must  be  connected  iu  a  group  of  two, 
whereby  the  electro-motive  force  is  halved,  and  the  size  of  the  cells 
doubled. 

Accumulators  seem  to  be  more  sensitive  for  this  -work,  especially 
when  there  is  a  direct  110-current  available  for  charging. 

The  use  of  the  continuous  current  in  diagnosis  and  as  a  therapeutic 
agent,  will  be  found  fully  discussed  iu  the  chapters  ou  Electro-Diagnosis 
and  Electro-Therapeutics. 

SINUSOIDAL  CURRENT. 

This  current  is  alternating  in  type,  and  derives  its  name  from  the 
fact  that  its  relation  to  time  follows  the  law  of  series.  It  bears  a  great 
similarity  to  the  ordinary,  pure  faradic  current,  in  so  far  that  its  motor 
effect  also  varies  according  to  the  rate  of  alternations.  When  the  alter- 
nations are  20  or  less  per  second, — i.e.,  when  they  are  very  slow, — the 
effect  produced  will  be  a  contraction  at  each  end  of  an  alternation. 
When  the  alternations  are  more  rapid, — say,  200  or  2000, — the  muscular 
contraction  becomes  tetanic. 

The  sinusoidal  current  has  a  smooth  and  gradual  variation.  It  is 
typically  adapted  for  muscular  stimulation,  and  by  a  properly  constructed 
apparatus  we  may  applj7  a  slightly  greater  milliamperage  than  the  pain- 
producing  properties  of  the  primary  induction  current  would  perm  it. 
The  ease  with  which  a  large  number  of  complete  alternations  per  second 
of  this  smooth  character  can  be  obtained,  renders  the  sinusoidal  current 
an  excellent  nerve  sedative. 


CHAPTER    IV 
FARADIC,  INTERRUPTED,  OR  INDUCED  CURRENTS. 

Principles  of  Induction. 

ACCORDING  to  a  natural  law  it  is  observed  that  when  two  distinct 
circuits  are  near  each  other,  currents  in  the  one  will  u  induce"  currents 
— or,  more  exactly,  electro-motive  forces — in  the  other.  These  induced 
currents  are  of  momentary  duration  and  appear  only  when  the  inducing 
current  is  made  to  vary,  as  is  instanced  when  the  current  is  made  or 
broken.  The  current  induced  at  the  beginning  of  the  inducing  current 
is  opposite  in  direction  to  the  inducing  current  itself ;  and  the  current 
induced  at  the  break  of  the  inducing  current  has  the  same  direction  as 
the  inducing  current.  The  strength  of  a  current  so  produced  is  propor- 
tional to  the  strength  of  the  producing  current  plus  the  length  of  the 
wire  subjected  to  the  influence  of  the  inducing  current  circuit.  The 
action  of  the  inducing  current  in  the  first  coil  is  augmented  if  there  be 
introduced  within  this  coil  a  soft  iron  core,  constituting  the  so-called 
electro -magnet. 

Based  upon  these  principles,  first  studied  by  Faraday  in  1832,  is  the 
faradic  or  induction  battery.  This  battery  consists  of  one  or  more  cells 
placed  in  circuit  with  a  primary  insulated  wire  surrounding  the  core,  and 
with  an  automatic  device  for  alternately  breaking  and  making  the  cell 
current.  Over  the  primary  coil  is  slipped  a  bobbin  having  another  coil 
of  insulated  wire  wound  around  it.  The  secondary  coil  has  no  connec- 
tion with  the  cell,  deriving  its  current  by  induction,  because  of  its  being 
placed  over  and  close  to  the  primary  coil  and  wire. 

MKDICAL  INDUCTION  COIL. 

The  principles  of  the  induction  coil  are  well  illustrated  in  Fig.  28. 
The  current  makes  a  circuit  from  the  cell  and  passes  through  the 
platinum  point.  A,  to  the  interrupter,  and  thence  through  the  primary 
coil :  the  latter  becomes  an  electro-magnet,  which  brings  about  the 
interruptions,  through  the  mechanism  of  the  hammer. 

The  heavy  line  indicates  the  primary  interrupted  current.  The 
light  line  indicates  the  induced  or  secondary  current. 

The  intensity  of  the  induced  current  can  be  regulated  by  sliding  the 

metallic  tube  in  or  out.  The  arrow  D  •* >•  I  indicates  that,  when 

the  sliding  tube  passes  in  the  direction  Z>,  there  is  a  decrease  of  current, 
because  of  a  decrease  in  the  area  of  the  magnetic  field,  and  vice  vers&. 


ELECTRO-THERAPEUTICS. 


The  operation  of  the  coil  is  as  follows  :  The  cell  current  proceeding 
from  the  carbon  pole  of  the  cell  traverses  the  primary  coil,  and  returns 
to  the  cell  through  the  interrupter,  the  platinum  points  of  the  latter 
being  in  contact.  In  the  act  of  traversing  the  coil,  this  current  makes 
the  core  magnetic,  which  in  turn  attracts  the  small  armature  on  the  in- 
terrupter, breaking  the  cell  current ;  the  magnetism  of  the  core  now 
having  disappeared,  the  spring  returns  to  contact,  when  the  process  is 
again  repeated.  On  closure  of  the  cell  current  a  reverse  induction 
arises  in  the  secondary  coil,  but  this  rises  slowly  on  account  of  self- 
induction  between  contiguous  windings  of  the  primary  coil.  At  the 
instant  of  opening  the  cell  current,  a  direct  current  arises  in  the  sec- 
ondary coil  of  a  much  sharper  curve  of  ascent  because  there  is  but  little 


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FIG.  28.— Medical  induction  coil. 

self-induction  to  interfere  with  it.  It  is  imperative  that  these  coils  shall 
not  touch  each  other  at  a  single  point.  Upon  opening  or  closing  the 
primary  circuit,  there  will  be  established  an  induced  current  in  the 
secondary  coil.  This  type  of  electric  current  is  produced  by  the  use  of  a 
medical  Ruhmkorff  coil.  The  screw  of  the  vibrating  hammer  should 
always  be  most  carefully  regulated.  Some  of  the  coils  have  two  kinds  of 
interrupters  accompanying  the  outfit.  One  of  these  is  slow,  while  the 
other  is  more  or  less  rapid.  Occasionally  the  hammer  requires  a  slight 
touch  of  the  finger  in  order  to  be  started  so  as  to  form  a  circuit 
between  the  coil  and  cell  or  battery.  The  current  produced  by  a  fa- 
radic  equipment  is  alternating  in  character,  as  may  be  readily  demon- 
strated when  applied  to  the  tissues.  Instead  of  a  current  from  a  cell. 
advantage  is  often  taken  of  a  direct  110-current,  as  is  well  illustrated  in 
Fig.  29. 


INI  )U(  'E I )  ( '  U  RRENTS. 


73 


INTERRUPTER  OR  RHEOTOME. 


The  interrupter  which  forms  an  essential  part  of  the  battery  is  the 
vibrating  spring  hammer  of  Xeef.  Many  authorities  condemn  this  form 
of  rheotome,  and  recommend  one  which  has  double  the  ordinary  spring 
length,  both  ends  being  attached  to  posts,  to  one  of  which  is  connected  a 
tension-screw  for  regulating  the  rate  of  vibrations.  The  armature  is 
attached  to  the  middle  of  the  brass  spring  and  platinum  plate  for  contact 
near  t lie  fixed  post.  Besides  regulating  the  frequency  and  amplitude  of 
the  vibrations  by  the  tension-screw,  we  regulate  them  also  with  the  set- 
screw  carrying  the  platinum  contact  point.  This  device  gives  easily  the 


FIG.  29. — Galvanic  and  faradic  lamp  controller. 

rate  of  vibration  suitable  for  muscular  contraction,  and  this  is  from  1  to 
about  3000  per  minute.  Vibrations  above  3000  per  minute  are  sedative. 
The  highest  stimulation  is  from  3000  to  4000  interruptions  per  minute. 

METHOD  OF  APPLICATION. 

This  method  of  electrization  consists  in  placing  one  pole,  generally 
the  negative,  at  the  feet  or  coccyx,  while  the  other  is  applied  to  any  part 
of  the  surface.  The  current  may  be  applied  (stabile)  stationary  or 
(labile)  moving  ;  it  may  be  increased  or  decreased  in  intensity  according 
to  the  desire  of  the  operator.  The  person  applying  it  should  have  some 
experience,  so  that  the  very  best  results  may  be  obtained. 


74  ELECTRO-THERAPEUTICS. 

LOCALIZED  FARADIZATION. 

Localized  farad  i/at  ion.  as  termed  by  Ducheime,  or,  more  correctly, 
polar  faradization,  in  contradistinction  to  the  polar  and  bipolar  method 
of  galvanization,  is  applied  in  precisely  the  same  manner  as  is  the  galvanic 
current.  This  localized  or  polar  method  has  eliminated  the  unscientific 
terms  "ascending"  and  "defending"  currents.  ^Nevertheless,  we  still 
speak  of  labile  and  stabile  currents,  one  of  the  electrodes  being  moved 
over  the  surface  or  both  being  stationary,  and  of  superficial  and  deep  or 
penetrating  currents;  the  former  with  a  dry  metallic  electrode  to  the 
dry  skin  and  superficial  nerves,  the  latter  with  moist  electrodes  to  the 
deep-seated  tissues. 

As  A  DIAGNOSTIC  AGENT. 

As  a  diagnostic  agent,  the  induction  current  is  of  value  for  de- 
termining the  increase  or  decrease  of  pathological  excitability,  and  in 
differentiating  between  central  and  peripheral  lesions.  The  tension 
current  (fine  coil)  is  sedative  in  character  and  is  valuable  in  quieting 
hysterical  suffering,  thus  affording  differentiation  between  pain  and  hys- 
teria in  gynecological  practice.  The  irritability  of  muscle  is  tested  by 
determining  the  lowest  power  of  the  faradic  current  which  will  contract 
it,  and  then  comparing  with  the  normal  side.  In  hysterical  paralysis,  the 
electro-contractility  is  usually  normal,  while  electro- sensibility  is  low- 
ered; in  infantile  paralysis  voluntary  contractility  is  increased,  whilst 
faradic  contractility  disappears.  So  also  in  the  reaction  of  degeneration, 
or  where  a  nerve  is  cut  in  its  continuity,  and  more  or  less  atrophy  or 
degeneration  is  found  in  both  muscle  and  nerve. 

As  A  THERAPEUTIC  AGENT. 

As  a  therapeutic  agent  the  induction  current  acts  on  nerves  and 
muscles,  stimulating  each  into  action  or  developing  anaesthetic  effects. 
Its  use  therefore  is  demanded  in  instances  of  nerve  or  muscle  pain.  Bi- 
polar electrodes  are  most  efficient  in  producing  contraction  of  relaxed 
pelvic  muscles,  including  the  uterus  itself :  in  other  cavities  and  mucous 
membranes  its  employment  is  becoming  general,  through  the  brilliant 
results  achieved  by  Apostoli. 


CHAPTER    V 
<  ATAPHORESIS.     HYDRO-ELECTRIC  BATH. 

I.   Cataphoresis. 

CATAPHORESIS  is  the  introduction  into  the  human  body  of  remedial 
agents  through  the  physical  properties  of  the  electrical  current.  Were 
the  procedure  electrolytic,  either  pole  could  be  applied. 

In  1859  Dr.  B.  W.  Richardson  l  produced  local  anaesthesia  by  apply 
ing  morphia  to  the  anode.  Since  then  various  experimenters  have 
succeeded  in  introducing  many  different  medicaments  by  this  process. 
Accurate  doses  are  easily  obtained.  A  piece  of  tissue  paper  or  absorbent 
cotton  is  patterned  to  fit  the  electrode,  and  the  desired  quantity  of  the 
agent  is  placed  upon  it ;  the  current  strength  varies  from  3  to  20  uiilli- 
amperes.  Cataphoresis  is  mainly  used  to  impress  the  skin  and  mucous 
membranes.  Chloroform  should  only  be  employed  as  a  counter-irritant,  as 
its  application  produces  a  dermatitis.  Helleboriu  and  acouitin  have  been 
successfully  used.  Figs.  30,  31,  32,  33  depict  various  forms  of  cataphoric 
electrodes. 

Rockwell  believes  that  i  '  the  effects  of  the  galvanic  current  upon 
nutrition  are  in  part  due  to  the  cataphoric  transfer  of  molecules  of 
protoplasm  and  liquid  from  one  cell  to  another,  or  from  a  cell  to  a  capil- 
lary vessel  in  the  path  of  the  auodal  stream,  and  since  the  diffusion  takes 
place  more  rapidly  and  more  quickly  in  direct  proportion  to  the  current 
strength,  it  behooves  us  to  employ  as  many  millianiperes  as  feasible  in  our 
galvanization  of  the  atrophied  and  paralyzed  extremities  of  poliomyelitis 
and  chronic  neuritis  and  peripheral  nerve  trauma." 

Dr.  James  C.  Gill,2  in  a  paper  read  at  the  Thirteenth  Annual  Meeting 
of  the  American  Electro-Therapeutic  Association,  September  23,  1903, 
entitled  ' { Cataphoresis, ' '  said :  "  I  believe  that  cocaine  used  with  the  aid  of 
cataphoric  action  of  electricity  is  the  ideal  method.  Its  use  requires  no 
great  amount  of  skill  and  no  expensive  complicated  outfit ;  an  ordinary 
galvanic  current  with  various  sized  electrodes  is  all  that  is  necessary. 
The  strength  of  the  current  or  the  solution  used  matters  but  little,  as  the 
stronger  the  solution  the  less  time  required  to  produce  the  desired  effect, 
and  a  high  amperage  is  undesirable  because  of  the  unpleasant  sensation 
from  the  electric  current.  The  advantages  of  cataphoric  anaesthesia  are 
these:  1.  Complete  amesthesia  without  pain,  which  fact  should  not  be 

1  Medical  Times  and  Gazette,  February  12  and  June  25,  1859. 

2  Journal  of  Advanced  Therapeutics,  July,  liX)4. 


ELECTRO-THERAPEUTICS. 


underestimated,  especially  wheii  dealing  with  an  acutely  inflamed  and 
hypersensitive  area,  such  as  is  frequently  found  in  certain  conditions 


FIG.  30. — Peterson's  cataphoric 
electrode. 


FIG.  ul. — Sectional  view  of  the  same. 


A  is  a  disk,  made  of  metal  that  will  not  oxidize.  The  stem  which  passes  through  the  hard- 
rubber  cover  Cis  held  in  place  by  nut  D.  It  also  holds  the  tip  for  connecting  with  the  battery.  B  is  a 
soft-rubber  ring,  which  is  held  in  place  by  A,  and  at  the  same  time  it  insulates  the  skin  from  .4,  allow- 
ing the  current  to  pass  from  A  to  the  skin  of  the  patient,  through  the  medicated  paper  contained  in  the 
cavity  formed  by  A  and  B.  (Courtesy  of  Waite  and  Bartlett  Manufacturing  Co.) 


FIG.  32.— Three  varieties  of  cataphoric  electrodes. 

The  one  furthest  to  the  left  consists  of  a  glass  jar,  covered  with  a  porous  earthy  material;  the  jar 
is  filled  with  the  solution  desired.  The  middle  electrode  is  that  of  Eisenberg,  made  of  ebonite  and 
covered  with  parchment.  The  right-hand  one  is  the  electrode  of  Dr.  Strauss,  which  because  of  its 
small  size  can  be  utilized  in  the  treatment  of  acne,  sycosis,  etc.  (From  the  catalogue  of  Reiniger- 
Gebbert  and  Schall.) 


FIG.  33.— Martin's  cataphoric  electrode. 

It  consist1)  of  a  metallic  plate  over  which  is  stretched  a  piece  of  parchment,  which  can  be  satu- 
rated through  the  tube  with  the  required  medicament. 

necessitating  the  use  of  the  knife.    2.  No  danger  from  constitutional  dis- 
turbances, as  the  cataphoric  action  of  the  current  brings  the  drug  in 


CATAPHORESIS.     HYDRO-ELECTRIC  BATH.  77 

contact  with  the  terminal  filaments  of  the  sensory  nerves,  and  not  into 
the  absorbents  as  does  the  hypodermic  injection,  a  sufficient  amount  is 
never  token  into  the  general  circulation  to  produce  any  noticeable  effect. 
Personally,  I  have  never  seen  any  disagreeable  symptom  from  its  use  in 
this  way.  3.  Xo  danger  of  formation  of  drug  habit.  Patients  do  not 
know  from  any  effect  upon  the  nervous  system  that  any  drug  has  been 
used.  4.  A  large  area  may  be  anaesthetized,  if  necessary,  with  the  absence 
of  unfavorable  symptoms.1' 

Dr.  G.  Betton  Massey.1  "The  Apostoli  Treatment;  Final  Results  in 
Some  Cases  of  Fibroid  Tumor  of  the  Uterus,"  records  the  final  results  of 
electrical  treatment  in  101  cases  of  fibroid  tumor,  so  far  as  they  could  be 
ascertained  by  personal  inquiries,  letters,  and  circulars.  In  some  of  the 
cases  the  treatment  had  stood  the  test  for  a  period  of  sixteen  years,  while 
in  none  had  less  than  three  years  elapsed.  The  tabulated  results  follow  : 

Cases  in  which  the  results  are  unknown 9 

Cases  resulting  in  anatomic  and  symptomatic  cure 22 

(Included  in  the  list  are  18  that  disappeared  by  absorption, 

while  3  were  extruded  through  the  cervix  in  whole  or  in  part, 

one  was  destroyed  piecemeal  by  electrolysis.) 

Cases  resulting  in  symptomatic  cure  only 53 

(These  include  12  with  great  reduction  in  size,  26  with  slight 
reduction  in  size,  and  15  permanently  relieved  of  symptoms 
without  change  in  size. ) 

Total  cases  resulting  in  practical  success 75 

Cases  resulting  in  partial  or  complete  failure 26 

Total  cases  treated 101 

Excluding  the  9  cases  in  which  the  results  are  unknown  it  will  be 
seen  that  the  figures  show  75  actual  or  practical  cures,  and  26  failures  in 
101  cases.  In  other  words,  75  per  cent,  of  the  cases  were  successful  and 
25  per  cent,  were  failures. 

II.  The  Hydro-electric  Bath. 

The  hydro-electric  bath  is  useful  in  many  diseases  for  its  stimulating 
and  tonic  effects  as  well  as  for  its  trophic  influence.  It  is  applicable  in 
anaemia,  chlorosis,  rickets,  rheumatism,  gout,  sciatica,  etc. 

The  bath  itself  should  be  made  of  porcelain  or  glazed  ware.  The 
w;iior  should  have  a  temperature  of  90°-98°  F.  (32°  to  37°  C.).  Two 
metal  electrodes,  that  must  always  be  kept  clean  and  bright,  are  placed  at 
the  head  and  foot  of  the  bath.  These  plates  are  attached  to  the  battery 
by  binding  screws.  The  larger  electrode  is  placed  at  the  head  of  the 

'Journal  of  the  American  Medical  Association,  May  21,  1904. 


78  ELECTKO-THERAPEUTICS. 

bath,  and  is  usually  1-Sx  12  inches  (45x30  cm.);  the  smaller  electrode  is 
11x9  (28x23  cm.).  In  order  to  localize  the  current  a  movable  paddle 
connected  to  the  foot-piece  is  often  employed.  A  wooden  rest  prevents 
the  back  and  shoulders  of  the  patient  touching  the  head-plate.  It  is 
immaterial  if  the  feet,  with  their  thickened  epidermis,  touch  the  foot-board 


FIG.  04.— The  four-celled  battery  of  Schnee. 

or  not.  A  part  of  the  current  traverses  the  body,  and  the  remainder 
•  s  through  the  water.  The  resistance  in  the  bath  depends  upon  its 
length,  the  depth  to  which  it  is  filled,  and  the  temperature  of  the  water. 
As  the  current  which  traverses  the  water  does  not  affect  the  patient,  it 
follows  that  only  so  much  water  should  be  used  as  is  required  to  cover  the 
l>;itiiMit  comfortably.  Xo  salt  should  be  added  to  the  water,  as  the  latin- 
thereby  becomes  a  better  conductor. 


CATAPHOEESIS.     HYDKU-ELECTKIC  BATH. 


The  duration  of  the  bath  should  be  ten  minutes  daily  for  the  first 
week,  but  after  that  it  should  be  given  on  alternate  days.     The  choice  of 
current  will  depend  upon  the  condition  present.    Thus,  in  the  early  stages 
of  general  neuritis,  in  acute  neuralgia,  and  in  acute  sciatica,  the  direct 
current  is  indicated.      In  gout,  rheumatism,  and  arthritic  conditions,  the 
galvanic  current  is  preferable.    The  induction-coil  bath  and  the  sinusoidal 
currents  are  useful  where  general  nutritive  effects  are  sought. 
Among  local  baths  may  be  mentioned  : 
THE  ARM:  BATH. 

THE  MONOPOLAR  AND  DIPOLAR  BATHS. 
THE  ELECTRIC  DOUCHE  BATH. 

The  arm  bath  is  useful  in  paralysis  of  the  muscles  of  the  forearms 
and  hands,  in  rheumatism  and  gouty  affections,  in  chilblains,  Raynaud's 
disease,  etc.  The  constant  current,  the  current  from  the  coil,  or  the 


r  F.      Th     UK 


—S>  9 


FIG.  35.— Diagrammatic  view  of    the  direction  of  current,  as  is  illustrated  in  Schnee's  four-celled 

battery. 

sinusoidal  current  may  also  be  employed.  The  bath  can  be  arranged  in 
any  non-conducting  vessel  ;  stone-ware  troughs,  easily  procurable  and 
inexpensive,  are  valuable  for  the  purpose. 

In  the  ni»n<>i>ol«r  bath  only  one  electrode  is  immersed,  the  whole  cur- 
rent passing  from  it  to  the  patient.  In  the  full-length  bath,  the  patient 
grasps  a  metal  conductor,  usually  a  bar  or  handle  which  is  covered  with 
a  piece  of  flannel,  and  secured  above  the  water  level.  The  current 
passes  from  the  conductor  to  the  hands,  thence  to  the  body,  and  finally  to 
the  water  of  the  bath  to  reach  the  other  conductor. 


80  ELECTRO-THERAPEUTICS. 

The  electric  douche  bath  originated  with  Trautweiu  in  1884. J  Dr. 
Guy6not,2  of  Aix  les  Baius,  has  described  a  method  of  electrical  ap- 
plication by  the  means  of  douches.  The  current  is  led  to  and  from  the 
patient  by  two  streams  of  water,  the  conductors  being  connected  to 
the  nozzles  through  which  the  water  flows,  the  jets  of  water  carrying 
the  current  to  the  whole  surface  of  the  body  or  to  the  special  part 
desired.  Those  interested  in  this  method  will  find  a  detailed  account  in 
the  original  paper. 

Dr.  SchneVs  four-celled  battery  is  convenient  and  practicable  for 
hydro-electrotherapy  (Figs.  34  and  35),  in  that  the  patient1  s  extremities 
are  alone  exposed  without  additional  disrobing.  It  is  comfortable  to  the 
patient,  the  current  is  regulated  by  a  switch-board,  and  the  parts  im- 
mersed allow  of  a  large  area  for  cataphoresis.  Duration  of  the  bath 
10  to  15  minutes.  Current  5  to  30  ma.  By  means  of  this  bath  elimina- 
tion of  metallic  poisons  from  the  body  has  often  been  accomplished. 

1Zeitschrift  f.  klin.Med.,  viii.,  p.  279,  1884. 

a  Revue  Internationale  d'Electrothe'rapie,  June,  1894. 


CHAPTER    VI 
ELECTKO-DIAGXOSIS. 

THE  examination  of  the  motor  nerves  and  muscles  is  of  paramount 
importance  in  electro-diagnosis,  consisting  in  localizing  the  current  with 
the  requisite  intensity  upon  these  parts. 

The  following  rules  should  be  followed  :  Apply  one  and  only  one 
pole  for  each  irritation  ;  the  effect  of  the  other  pole  should  be  repressed 
as  much  as  possible. 

For  the  local  irritant  effect  use  the  active  or  irritant  electrode  ;  the 
other  is  termed  the  indifferent  electrode. 

Have  the  active  electrode  as  small  as  possible  so  as  to  secure  the 
greatest  density  of  current. 

Have  the  indifferent  electrode  as  large  as  possible,  so  that  the  density 
may  be  slight  and  ineffective.  Place  the  indifferent  electrode  upon  the 
sternum,  the  back  of  the  neck,  or  the  small  of  the  back. 

The  changes  liable  to  occur  in  testing  nerves  and  muscles  are  changes 
in  the  visible  muscular  responses.  As  there  may  be  changes  in  the 
behavior  of  the  muscles  both  to  the  coil  and  the  cells,  both  forms  of  exci- 
tation are  used  in  examining  a  muscle.  The  active  electrode  should  be 
applied  either  to  the  muscle  or  near  its  motor  point.  In  testing  a  muscle, 
the  indifferent  electrode  should  be  applied  to  the  skin  with  an  even  and 
firm  pressure.  The  electrodes  and  the  surface  of  the  body  should  be  well 
moistened.  "Water  containing  a  saline  diminishes  the  resistance  of  the  skin, 
but  offers  the  disadvantage  of  acting  upon  the  electrode.  With  some 
of  the  small  muscles  of  the  hands  and  feet,  it  is  convenient  to  apply  both 
electrodes  over  the  part,  so  that  the  current  may  pass  directly  through. 

The  Motor  Points. 

These  are  the  points  to  which  the  testing  electrode  should  be  applied, 
in  order  to  effect  contraction  in  the  adjacent  muscle,  or  they  are  the 
points  at  which  the  motor  nerve  trunks  can  readily  be  reached.  The 
positions  of  the  motor  points  vary  somewhat  in  different  individuals. 

The  motor  point  can  be  absolutely  located  only  by  experiment.  Sub- 
cutaneous fat  acts  as  a  barrier,  and  the  examination  of  the  deeper  muscles 
is  more  trying  than  the  superficial  ones.  The  limb  should  be  supported 
by  the  operator  and  the  muscles  relaxed  as  much  as  possible.  Begin  with 
a  current  capable  of  producing  a  small  muscular  contraction,  applying 
the  current  for  a  brief  period  only. 

Points  favorable  for  the  stimulation  of  nerve  trunks.1 

1  The  subjoined  series  of  tables  are  taken  from  the  work  of  H.  Lewis  Jones,  M.D., 
on  "Medical  Electricity." 

6  81 


82 


ELECTRO-THERAPEUTICS. 


IN  THE  UPPER  LIMB.     (Figs.  36,  37,  38,  and  39.) 

1.    The  mwlian,  along  the  inner  border  of  the  biceps,  and  at  the  bend 
of  the  elbow. 


Caput  externus  M.  tricipitis 


N.  radialis 

M.  brachialis  interims 

M.  supinator  longus.... 

M.  radialis  externus  longua-- 

M.  radialis  externus  brevis 

FIG.  36.— Motor  points  of  the  arm 

M.  supinator  lonpus „ 

M.  radialis  externus  longus 


M.  radialis  externus  brevis 


M.  extensor  digitorum  communism 

M.  extensor  indicis  proprius 

M.  extensor  indicis  proprius  et  M. 

abductor  pollicis  lonpus 

M.  abductor  pollicis  longus - 


M.  extensor  pollicis  brevis 
M.  flexor  pollicis  longus 


M.  interosseus  dorsalis  I 
M.  interosseus  dorsalis  II 
M.  interosseus  dorsalis  III 


_M.  ulnaris  externus. 


M.  extensor digiti  minimi  pro- 
prius. 


M.  extensor  indicis  proprius. 
M.  extensor  pollicis  longus. 


•M.  abductor  digiti  minimi. 
.M.  iuterosseus  dorsalis  IV. 


FIG.  37.— Motor  points  of  the  forearm  and  hand. 

2.   Th<   nhmr.   in  the  groove  between  the  internal  condyle  and  the 


oleeranon. 


ELECTRO-DIAGNOSIS. 

N".  Musculo-cutaueus.      M.  biceps. 


83 


N.musculo-  Caput  in-     N.  Media- 
cutaiK-us.    ternusM. 
tricipitis. 


nus.    M.  brachialis 
internus. 


N.  ulnaris.  Kami  X.  median! 
pro  M.  pronatore 
radii  terete. 


FIG.  38.— Motor  points  of  the  arm  (front  view) 


Ranii  Nervi  median!  pro  M.  pro 
natore  radii  terete 


M.  palinaris  longus.. 


M.  ulnaris  internus. 


M.  flexor   ditritorum    snblimis 
(digitt.  II  et  III.) 


N.  ulnaris 

M.   flexor    digitorum   sublimis 
(digitt.  indiiis  et  miniin) 


Kami  volar.  prof.  Nervi  ulnaris. 
M.  palmaris  brevis 

M.  abductor  digiti  minimi , 

M.  flexor  digiti  minimi 

M.  opponens  digiti  minimi 

Mm.  lumbricales  II,  III  et  IV 


M.  radialis  interims. 
M.  flexor  digitorum  profnndua. 


M.  flexor  digitorum  sublimis. 


M.  flexor  pollicis  longns. 
N.  medianus. 


M.  abductor  pollicis  brevig. 
M.  opponens  pollicis. 

M.  flexor  pollicis  brevia. 
M.  adductor  pollicis. 
M.  lumbricalis  I. 


FIG.  39.— Motor  points  of  the  forearm  and  hand  ( front  view). 


S4 


ELECTRO-THERAPEUTICS. 


3.  The  musculo-spiml,  at  the  point  where  it  emerges  from  the  triceps, 
namely,  on  the  outer  side  of  the  upper  arm  about  the  junction  of  the 
middle  and  lower  thirds. 


N  cruralis 

N.  obturatorius. 
M.sartorius 


M.  adductor  longjs 

Kami  N.  cruralis  pro  M.  quadrici- 
pile. 

M.  cruralis 

Bami  N.  cruralis  pro  M.  vasto  in- 
teruo 


M.  tensor  vaginae  femoris.  (Rami 
N.  glutsei  superioris.) 

M.  tensor  vaginae  femoris.  (Ram! 
N.  cruralis.) 


M.  rectus  femoris. 


M.  vastus  externus. 


M.  vastua  externus. 


Fig.  43.- Motor  points  of  the  thigh. 


M.  peroneus  longus 
M.  tibialis  anticus 


•  '•  '."'•< f  •',.:'." 

• 


.N.  peroneus. 

.M.  gastrocnemius  externus. 

.M.  soleus. 

.M.  extensor  digitorum  longua. 


M.  peroneus  brevis. 
M.  soleus. 


...  M.  flexor  hallucis  longua 


II.  extensor  hallucis  longus 


Rami   X.  pcronei  prof,  pro  M. 
extensore  digitorum  brevi 


Mm.  interossei  pedis  donates.  <  —-*$£, 


.M.  extensor  digitorum  brevis. 


.M.    abductor    digiti    minimi 
pedis. 


Fro.  41.— Motor  points  of  the  leg  and  foot. 


4.  The  musculo-cutaneous,  between  the  biceps  and  coraco-brachialis 
muscles. 


ELECTRO-DIAGNOSIS.  85 

5.  The  long  thoracic  (serratus  maguus),  on  the  inner  wall  of  the 
axilla. 

6.  The  supra-clavicular  point  of  Erb.     "  At  a  spot  one  inch  above 
the  clavicle,  and  a  little  externally  to  the  posterior  border  of  the  sterno- 
niastoid,  immediately  in  front  of  the  transverse  process  of  the  sixth  cer- 
vical vertebra,  a  simultaneous  contraction  can  be  produced  in  the  deltoid, 
biceps,    coraco-brachialis,    brachialis    auticus,  and   supiuator   lougus." 
This  is  a  motor  point  for  the  fifth  and  sixth  cervical  roots  before  they 
reach  the  brachial  plexus. 

IN  THE  LOWER  LIMB.     (Figs.  40,  41,  42,  and  43. ) 

7.  The  anterior   crural,   in  the  fold  of  the  groin  just  outside  the 
femoral  artery. 

8.  The  sciatic,  just  below  the  gluteal  fold  at  the  back  of  the  thigh. 

9.  The  internal  popliteal  nerve,  in  the  popliteal  space,  and  to  the 
inner  side  of  the  teudo  Achillis. 

10.  The  peroneal  nerve,   just   above  the  head  of   the  fibula,  beside 
the  biceps  tendon. 

IN  THE  FACE.     (Fig.  44.) 

11.  The  facial,  through  the  cartilage  of  the  lower  surface  of  the 
meatus  auditorius.     Its  chief  ramifications  can  be  reached  where  they 
emerge  from  the  parotid  gland.     Erb  chooses  for  stimulation  three  main 
branches  of  the  facial  :  (a)  for  muscles  above  palpebral  aperture;  (b) 
for  muscles  in  front  of  upper  jaw,  between  the  orbit  and  the  mouth ; 
(c)  for  muscles  of  the  lower  jaw.     He  tests  each  of  these  in  two  places, 
first  at  points  just  in  front  of  the  ear,  and  secondly  for  (a)  at  the  temple, 
for  (b)  at  anterior  extremity  of  zygomatic  bone  near  its  lower  border, 
for  (c)  at  the  middle  of  the  inferior  border  of  the  horizontal  ramus  of 
the  lower  jaw. 

12.  The  fifth,    at    the  supra-orbital    foramen,    at   the  infra-orbital 
foramen,  at  the  foramen  mentale,  on  the  side  of  the  tongue. 

IN  THE  NECK.     (Fig.  44.) 

13.  The  spinal  accessory,  at  the  top  of  the  supra-clavicular  triangle, 
where  the  nerve  pierces  the  sterno-mastoid. 

14.  The  phrenic,  on  the  outer  edge  of  the  lower  part  of  the  sterno- 
mastoid. 

15.  The  hypogJossaJ,  along  the  upper  border  of  the  great  cornu  of 
the  hyoid  bone. 

16.  The  recurrent  laryngeal,  along  the  outer  border  of  the  trachea. 

17.  The  pneumogastric  and  glosso-pharyngeal,  along  the  track  of  the 


ELECTEO-THERAPEUTK  S. 


Kami  inferiores  N  glutsei  inferioris 

pro  M.  glutaeo  maxiuio 

N.  ischiadicus -1^----  \  ;!:;iw  — -M.  adductor  mapnus. 

M.  biceps  (caput  longum) -IP—  -/;- ••••     •  -^  >:  •emitendlnomia. 

:IS  ----- -M.  Bemlmejnbnuuma 

•fc    . 
M.  biceps  (caput  breve) 


N.  tibialis 

N.  peroneus 

M.  gastrocnemius  externus 

M.  Boleus 


M.  gastrocnemiua 


FIG.  42. — Motor  points  of  the  thigh  and  leg  (posterior  view). 


M.  gastrocnemius  internus 
1C.  soleus 


If.  flexor  digitorum  longus 


N.  tibialis 


M.  abductor  hallucis 


Fio.  4:?.— Motor  points  of  the  leg  and  foot  (inner  side). 


ELECTRO-DIAGNOSIS. 


87 


carotid  artery  just  below  the  angle  of  the  jaw.     Fig.  45  illustrates  the 
motor  points  of  the  chest  and  abdomen. 

When  paralysis  affects  certain  groups  of  muscles,  and  difficulty  is 


!;  M.corrugatorsupercil. ;  2,  M.eonr 
pressor  nasi  et  pyramidal,  nasi :  :;.  M 
orbicular,  palpebr.  :  4,  M.  levator  lal> 
sup.  alaeque  nasi :  5,  M.  levator  lab.  sup- 
propr. ;  6,  M.  zygomatic.  minor  :  7.  M. 
dilatat.narium  ant.  et  post.:  S.  M. zygo- 
matic. major:  y,  M.  orbicularis  oris: 
10,  Ram.  comm.  pro  Mm.  triangular. 
et  levator  menti:  11,  M.  levator  menti : 
12,  M.quadratus  menti:  13,  M.triangii- 
laris  menti;  14,  Ram.  subcutan.  colli 
X.  facial.;  15,  Ram.  cervical,  pro  Pla- 
tyMiiat.;  1C.  M.  stern o-hyoideus  :  17.  M. 
o'mo-hyoideus ;  18,  M.  sterno-thyroi- 
deus ;  19,  M.  sterno-hyoideus ;  20,  M. 
frontalis  :  21,  Mm.  attrahens  et  atlol- 
lens  auriculae ;  22,  Mm.  retrahens  et 
attoll.  auriculae;  23,  M.  occipitalis ; 
24,  Xerv.  facialis;  25,  Ram.  auricular, 
post. prof. X. facialis;  2f.,  M.  .-tylo-hyoi- 
d.'us  ;  27,  M.  digastricns:  28,  Ram.  buc- 
cales,  X.  facialis:  29,  M.  splenius  capi- 
tis  :  30,  Ram.  subcutan.  maxill.  infer.; 
31,  Ram.ext.  X.  accessor!!  Willisii;  32, 
M.  .-terno-cleido-mastoideus :  33,  M. 
cucullaris  :  34,  M.  sterno-cleido-mas- 
toideus ;  35,  M.  levator  anguli  scap- 
ulae ;  36,  N.  thoracic,  post.  (Mm.  rhom- 
boidei) ;  37,  X.  phrenicus ;  38,  M.  omo- 
hyoid  ;  39.  X.  thoracic,  lateral.  <M. 
serrat.  magn.)  ;  40,  X.  axillaris ;  41, 
Ram.  plex.  brachialis  (X.  musculo- 
011  tan.,  pars  X.  medianii;  42,  X.  tho- 
racic, ant.  (M.  pectorales). 


Fio.  41.— Motor  points  of  the  head  and  neck. 


M.  rectus   ab- 

dominis. 
(Nervi  intercos- 
tales       abdomi-  - 
nales.) 


M.    serratus    Mag 
nus. 
M.latissimus  dorsi. 


M.  obliquus  ab- 
dominis  exter- 
nus. 

f  (Nervi  intercos- 
tales  abdonii- 
nales.) 


M.  transversus  ab- 
domiuis. 


7 


Flo.  45.— Motor  points  of  the  chest  and  abdomen. 

experienced,  as  it  frequently  is,  in  tracing  the  nerve  supply  of  the  mus- 
cles involved  back  to  their  spinal  roots,  advantage  may  be  gained  by 
employing  the  table  by  Dr.  Allen  Starr.1 

1  Brain,  1894. 


88  ELECTRO-THERAPEUTICS. 

SEGMENTS. 

4th  cervical. — Diaphragm,  levator  auguli  scapulie,  deltoid,  rhom- 
boids, spinati,  biceps,  supiuator  longus. 

5th  cervical. — Rhomboids,  spinati,  teres  minor,  deltoid,  pectoralis 
major  (clavicular  portion),  biceps,  serratus  magnus,  supiuator  longus 
and  brevis. 

6th  cervical. — Latissimus  dorsi,  pectoralis  major,  serratus  magnus, 
pronators,  biceps,  triceps,  brachialis  auticus,  extensors  of  the  wrist  and 
fingers. 

7th  cervical. — Teres  major,  latissimus  dorsi,  subscapularis,  pectoralis 
major  and  minor,  triceps,  flexors  of  the  wrist  and  fingers. 

8th  cervical. — Flexors  of  the  wrist  and  fingers,  extensors  of  the 
thumb,  intrinsic  muscles  of  hand. 

1st  dorsal. — Extensors  of  the  thumb,  intrinsic  muscles  of  the  hand 
(thenar,  hypothenar,  interossei). 

For  the  lumbar  enlargement  Dr.  de  Watteville1  gives  the  following 
distribution : — 

3d  lumbar. — Ilio-psoas,  sartorius,  adductors,  extensor  cruris. 

4th  lumbar. — Extensor  femoris  et  cruris  ;  peroneus  lougus  ;  adductors. 

5th  lumbar. — Flexors  and  extensors  of  toes,  tibial,  sural,  and  perom-ul 
muscles,  extensors  and  rotators  of  thigh,  hamstrings. 

1st  sacral. — Calf,  hamstrings,  long  flexor  of  great  toe,  intrinsic 
muscles  of  foot. 

2d  sacral. — Intrinsic  muscles  of  the  foot. 

Dr.  Herringham2  has  also  tabulated  the  results  of  numerous  dissec- 
tions of  the  brachial  plexus  in  new-born  infants  as  follows  : 

USUAL  XEEVE  SUPPLY. 

3d,  4th,  and  5th  cervical. — Levator  anguli  scapulae. 

5th.  — Rhomboids. 

5th,  or  5th  and  6th  cervical. — Supraspinatus,  iufraspinatus,  teres 
minor. 

5th  and  6th  cervical. — Subscapularis,  deltoid,  biceps,  brachialis 
anticus. 

6th  cervical. — Teres  major,  pronator  radii  teres,  flexor  carpi  radiales. 
Supinator  longus  and  brevis.  Superficial  thenar  muscles. 

5th,  6th,  and  7th  cervical. — Serratus  magnus. 

6th  or  7th  cervical. — Extensores  carpi  radiales. 

7th  cervical. — Coraco-  brachial  is,  latissimus  dorsi,  extensors  at  the 
back  of  the  forearm,  outer  head  of  triceps. 

7th  and  8th  cervical. — Inner  head  of  triceps. 

1  Lancet,  July  14,  1883. 
»Proc.  Roy.  Sec.,  March,  1866. 


ELECTKO-DIAGXOSIS.  8l> 

7th,  8th,  and  1st  dorsal. — Flexor  sublimis  and  profuudus,  flexor  carpi 
ulnaris,  flexor  longus  pollicis,  and  pronator  quadratus. 

8th  cervical. — Long  head  of  triceps,  hypotheuar  muscles,  interossei, 
deep  thenar  muscles. 

The  pectoralis  major  from  6th,  7th,  8th,  and  1st  dorsal. 

The  pectoralis  minor  from  7th,  8th,  and  1st  dorsal . 

Hints  for  Practical  Testing. 

Always  begin  testing  with  the  induction  coil  and  finish  with  the 
cells.  Do  not  use  very  strong  currents  from  the  coil.  If  the  muscles  do 
not  respond  to  these  currents,  increase  the  strength  of  the  latter.  The 
operator  should  first  apply  the  current  to  his  own  person,  so  as  to  reas- 
sure the  patient.  With  battery  currents  start  with  about  16  cells  for 
the  limbs  and  8  cells  for  the  face.  The  testing  electrode  should  be  the 
cathode.  If  upon  passing  no  noticeable  contraction  is  discerned  in  the 
muscles,  increase  the  number  of  cells,  upon  the  first  closure  contraction, 
look  for  the  most  effective  spot  for  stimulating  the  muscle,  and  compare 
the  AC1C  with  the  CC1C.  Observe  the  character  of  the  contraction, 
whether  quick  or  sluggish.  Compare  the  direct  with  the  indirect  stimu- 
lation through  the  nerve  trunk  ;  compare  the  reactions  obtained  with 
those  of  the  unaffected  side. 

Disease  or  injury  may  cause  quantitative  changes  or  changes  in  the 
amount  of  reaction  to  a  stimulus,  the  quality  of  the  reaction  remaining 
unaltered,  as  is  exemplified  in  simple  increase  of  excitability  and  simple 
decrease  of  excitability  to  coils  and  cells. 

In  unilateral  disease,  the  recognition  of  increased  or  decreased  ex- 
citability is  easy  when  this  increase  or  decrease  is  marked ;  but  when 
slight,  there  are  many  disturbing  factors  that  may  lead  to  an  error  of 
judgment. 

With  the  battery  current,  the  galvanometer  is  a  reliable  guide. 
Unequal  pressure  of  the  electrode,  when  comparing  two  points,  may 
cause  an  apparent  difference  in  irritability.  The  resistance  of  the  skin 
is  likewise  inconstant  during  a  test. 

Increased  irritability  usually  occurs  in  those  conditions  presenting 
increased  reflexes,  as  in  chronic  myelitis,  in  degeneration  of  the  lateral 
columns,  in  hemiplegia,  and  in  tetany. 

Decreased  irritability  is  evidenced  in  many  diseases,  offering  quali- 
tative changes  also  when  the  condition  is  more  severe.  Thus  in  neuritis 
we  may  observe  either  qualitative  or  quantitative  changes,  according  as 
the  attack  is  mild  or  severe. 

Qualitative  changes  are  changes  affecting  the  quality  of  the  reaction. 
This  includes  the  reaction  of  degeneration,  both  complete  and  partial, 
also  the  myotonic  reaction,  etc. 


90  ELECTRO-THERAPEUTICS. 

Reaction  of  Degeneration.   (De.  R. )  or  (R.  D.) 

This  term  was  proposed  by  Erb,  to  signify  the  series  of  changes 
occurring  in  electrical  irritability,  both  qualitative  and  quantitative, 
owing  to  a  certain  definite  morbid  condition  of  nerves  and  muscles. 
The  effect  of  the  faradic  current  diminishes  and  disappears,  but  with  the 
galvanic  current,  decided  changes  are  manifested.  Lesions  of  motor 
nerves,  either  at  the  spinal  centre  or  in  the  course  of  peripheral  dis- 
tribution, of  sufficient  importance  to  produce  paralysis,  will  rapidly 
show  pronounced  galvanic  and  faradic  changes.  The  nerve  will  exhibit 
a  progressive  diminution  of  electrical  excitability,  and  a  few  days  sub- 
sequently it  will  have  ceased  entirely.  Rarely  a  fortnight  elapses  before 
complete  cessation  of  excitability  is  noted.  The  point  of  departure  is 
always  at  the  extremity,  nearest  the  injury  or  lesion,  degeneration  pro- 
ceeding thence  toward  the  periphery.  When  reparative  action  has 
begun,  excitability  returns,  recovery  showing  itself  at  the  point  of  begin- 
ning degeneration.  Frequently  muscles  may  respond  to  the  patient's 
will,  but  they  do  not  respond  to  electrical  currents;  showing  that  while 
the  nerve  will  transmit  the  voluntary  impression,  it  will  not  necessarily 
transmit  other  impressions. 

DEGENERATION  OF  MUSCLES. 

In  degeneration,  muscles  differ  from  nerves  in  their  electrical  reac- 
tions. With  the  faradic  current,  however,  the  reactions  are  identical  Vxrth 
in  quality  and  quantity.  The  faradic  current  has  no  effect  on  muscle 
tissue,  save  for  the  nerve  supplying  it.  With  the  galvanic  current,  mus- 
cular tissue  for  the  first  few  days  contracts,  with  a  somewhat  lessened  ac- 
1  ivity  ;  its  response  to  a  certain  strength  of  current  is  not  so  marked  as  in 
the  normal  condition.  For  several  succeeding  days,  the  irritability  of 
the  muscle  is  increased.  This  may  last  for  weeks,  and  sometimes  during 
this  condition  a  change  in  the  normal  sequence  of  contraction  occurs. 
the  contractions  changing  in  character  as  well  as  in  quality.  They  assume 
a  slow  tetanoid  form,  which  continues  during  the  flow  of  the  current, 
the  strength  of  the  current  required  being  notably  small.  Soon  in  the 
stage  of  degeneration  the  AnCIC  =  CaCIC,  and  a  little  later  exceeds  it  ; 
this  is  accompanied  by  the  CaOC  gaining  upon  the  AnOC,  but  never 
being  equal  to  it.  Thus  we  obtain  the  following  formula  for  the  normal 
muscular  reaction  to  galvanism  : 

CaCIC  >  AnCIC  >  AnOC  >  CaOC. 

For  the  reaction  of  degeneration,  the  formula  : 

AnCIC     :  CaCIC  or  AnCIC  >  CaCIC  >  AnOC  diminished,  but  always  >  CaOC. 


ELECTRO-DIAGNOSIS.  !>l 

PARTIAL  REACTION  OF  DEGENERATION. 

This  term  is  applied  to  cases  in  which  contraction  is  evidenced  to 
some  degree  by  the  coil,  but  to  the  battery  current  the  response  is 
sluggish. 

The  existence  of  partial  reaction  of  degeneration  makes  it  necessary, 
when  testing,  always  to  corroborate  the  results  obtained  from  the  coil  by 
employing  the  battery  current.  In  partial  reaction  of  degeneration  there 
is  found  an  alteration  in  the  coil  reactions,  but  this  may  be  overlooked, 
and  thus,  conclusions  arrived  at  from  the  presence  of  coil  reactions 
would  be  wrongly  interpreted.  The  degree  of  sluggishness  of  contrac- 
tions may  vary  within  wide  limits,  the  reaction  to  the  coil  may  be  faint 
or  very  strong.  By  some  it  is  held  that  partial  reaction  of  degeneration 
represents  a  changing  state  of  the  nerve  or  muscle,  and  that  a  change  to 
complete  reaction  of  degeneration  on  the  one  hand,  or  to  a  normal  re- 
action on  the  other,  may  be  looked  for  in  cases  showing  partial  reaction 
of  degeneration. 

THE  SENSORY  SYSTEM. 

Little  can  be  said  on  the  subject  of  alterations  in  the  electrical 
reactions  of  the  sensory  nerves,  and  but  faint  light  can  be  thrown  on  the 
irritability,  conductivity,  location,  etc.,  of  the  sensory  nervous  system. 
An  increase  in  the  impressions  conveyed  by  the  cutaneous  filaments  of 
the  sensory  nerve-fibres  indicates  electrical  cutaneous  hyperaesthesia, 
while  impairment  of  this  function,  corresponding  largely  with  the  definite 
reactions  of  the  motor  system,  constitutes  electrical  cutaneous  anesthesia. 
In  diseases  involving  the  sensory  tractvS  of  the  cord,  the  diagnosis  is 
materially  aided  by  finding  this  anaesthesia  and  hyperaesthesia. 

XERVES  OF  SPECIAL  SENSE. 

Under  this  heading  we  shall  only  notice  the  auditory  nerve,  which 
allows  of  material  aids  in  diagnosis,  through  its  irritablity  in  tinnitus 
auriuin.  Like  motor  nerves,  the  auditory  responds  more  readily  to 
cathodal  than  to  anodal  stimulation,  the  response  being  the  production 
of  a  subjective  sensation  of  sound ;  in  certain  abnormal  conditions  the 
auditory  nerve  answers  to  electrical  currents  more  readily  than  it  does 
in  health.  In  these  cases  it  is  contended  that  a  state  of  hyperaesthesia 
exists  in  the  nerve,  and  that  tinnitus  is  an  expression  of  that  state.  To 
test  the  auditory  nerve,  use  a  bifurcated  electrode  applied  to  both  ears  at 
once.  By  this  method  there  is  less  likelihood  of  provoking  giddiness. 
If  a  biuaural  stethoscope  is  used  as  a  temporary  expedient,  the  lower 
portion  should  be  removed,  and  the  tubes  closed  up  with  small  corks; 
the  battery  wire  is  attached  to  the  metal  and  the  other  electrode  is 
placed  indifferently. 


CHAPTER   VII 
ELECTRO-PHYSIOLOGY. 

THE  diagnosis  of  pathological  conditions  can  in  many  instances  be 
more  accurately  investigated  by  a  thorough  preliminary  understanding  of 
a  study  of  the  electrical  current  influences  upon  the  normal  physiological 
functions. 

INFLUENCE  OF  ELECTRICITY  UPON  MOTOR  NERVES  AND  MUSCLES. 

The  motor  nerves,  when  irritated  by  the  galvanic  or  faradic  current, 
give  rise  to  a  muscle  contraction.  According  to  Du  Bois-Reyniond  : 

' '  The  absolute  amount  of  the  density  of  the  current  at  any  certain 
moment  does  not  act  as  a  stimulant  to  the  motor  nerves,  but  merely  the 
change  in  its  amount  from  one  moment  to  another,  i.  e. ,  in  the  density  ; 
these  act  so  much  more  powerfully  the  greater  they  are  in  a  unit  of 
time,  or,  their  amount  being  equal,  the  more  rapidly  they  occur ;  most 
powerfully  therefore  upon  sudden  closure  and  opening  of  the  current. 

"  Thus  the  reason  of  the  marked  irritative  effect  of  the  faradic  cur- 
rent on  motor  nerves  at  once  becomes  apparent ;  whilst,  on  the  contrary, 
a  constantly  flowing  galvanic  current,  or  a  very  gradual  increase  or 
decrease  in  the  current  strength,  produces  no  stimulation  whatsoever.  If 
induction  currents  are  applied  to  a  motor  nerve,  a  series  of  brief  muscular 
contractions,  corresponding  to  the  strength  of  the  induced  current,  will  be 
produced  ;  these  contractions  necessarily  being  greater  during  the  open- 
ing than  during  the  closing  current  of  the  secondary  coil.  A  long  series 
of  these  irritations  results  in  a  tetanic  contraction. ' ' 

PFLUGER'S  LAWS  OF  CONTRACTION. 

"With  weak  currents  in  both  directions,  contraction  occurs  on  closure 
alone,  but  none  is  produced  on  opening  ;  the  contraction  on  closure  of 
the  ascending  current  is  somewhat  stronger  than  that  of  the  descending. 

"With  moderate  currents  contraction  occurs  on  opening  and  closing 
in  both  directions ;  but  the  former  are  always  weaker  than  the  latter. 

"With  very  strong  currents  (never  employed  upon  human  beings) 
contraction  occurs  on  opening,  but  none  on  closure  of  the  ascending  cur- 
rent ;  and  it  also  occurs  on  closure,  but  not  on  opening  of  the  descending 
current." 

These  laws  only  hold  good  when  the  nerve  is  laid  bare  and  well 
isolated. 

92 


ELECTRO-PHYSIOLOGY.  93 

In  illustration  of  the  above  laws  we  need  only  refer  to  the  irritative 
effect  produced  by  the  galvanic  current,  which  occurs  only  at  the  poles, 
and  starts  from  them,  and  note  that  the  irritation  upon  closing  the  circuit 
occurs  only  at  the  cathode,  and  upon  opening,  only  at  the  anode.  Long 
ago  it  was  proved  that  the  irritant  action  of  the  cathode  was  greater  than 
that  of  the  anode  ;  thus  the  irritation  on  closure  is  greater  than  at  the 
opening,  with  the  same  intensity  of  current.  Likewise  the  central  part 
of  a  nerve  is  more  irritable  than  the  peripheral  portion,  and  with  very 
strong  currents  considerable  resistance  occurs  at  both  poles  and  increases 
with  the  strength  and  period  of  closure  of  the  current.  Furthermore 
motor  nerves  are  non-irritable  to  the  transverse  passage  of  the  faradic 
or  galvanic  current,  and  a  motor  nerve  which  is  still  connected  to  a 
central  organ  has  its  opening  contraction  of  the  ascending  current  con- 
siderably later  than  when  the  (motor)  nerve  is  isolated. 

Thus  far  we  have  been  dealing  with  electrical  currents  on  motor 
nerves  studied  physiologically,  but  the  results  obtained  are  not  analogous 
with  the  practical  results  obtained  by  the  physician.  The  latter  deals  with 
nerves,  surrounded  by  tissues  of  good  conduction  and  which  are  followed 
by  large  numbers  of  threads  of  currents  ;  illustrating  the  absolute  futility 
of  maintaining  a  uniform  density  of  current  in  a  nerve.  The  greatest 
density  of  current  must  occur  directly  at  the  electrodes.  Because  of  the 
various  threads  of  current,  the  direction  of  the  latter  must  be  omitted 
from  consideration  in  applying  electricity  to  the  healthy  human  body. 

In  the  polar  method  of  examination,  one  electrode,  called  the 
"active,"  is  applied  closely  to  the  nerve  and  then  connected  with  either 
the  anode  (An)  or  cathode  (Ca)  of  the  battery.  The  other  electrode, 
termed  the  "indifferent,"  is  placed  upon  some  distant  part  of  the  body, 
as  the  sternum,  spine,  epigastrium,  etc.  If  the  cathode  is  upon  the 
nerve  and  the  circuit  is  closed,  the  term  "making  a  cathode  closure" 
is  employed,  and  is  written  CaCl  ;  if  the  circuit  is  open  it  is  desig- 
nated "cathode  opening,"  and  is  written  CaO,  and  similarly  with  the 
anode. 

Begin  with  a  definite  strength  of  current  by  examining  CaCl  in 
about  three  closures,  at  the  same  time  studying  the  CaO,  and  thus  also 
with  the  auodal  contractions. 

For  the  opening  contraction,  keep  the  current  closed  for  a  brief 
period,  as  the  irritability  on  opening  the  circuit  is  thus  augmented.  By 
an  increase  of  current,  we  gauge  the  degree  of  intensity  of  current  for 
the  various  forms  of  contraction. 

By  this  method  it  is  readily  demonstrated  that  with  most  of  the 
motor  nerves  the  cathode  chiefly  produces  stimulation  on  closure,  the 
anode  principally  on  opening,  and  that  the  stimulant  action  of  the  cath- 
ode is  much  greater  than  that  of  the  anode. 


!'l  ELECTRO-THERAPEUTICS. 

Iii  inediciue  three  stages  of  contraction  are  distinguished  : 

First  stage  ( feeble  current )  CaClC. 

Second  stage  (moderate  current)  CaClC'  is  stronger.  AuCIC  and 
AnOC  also  occur  and  are  fur  all  practical  purposes  of  about  equal 
strength. 

Third  stage  (strong  current)  CaClC"  becomes  tonic  and  equals 
CaClTe  ;  AuCIC  (and  especially  AnOC')  becomes  more  powerful  and  at 
the  same  time  weak  CaOC  occurs. 

UPON  VOLUNTARY  MUSCLES. 

Du  Bois-Reymond's  law  of  motor  nerve  stimulation  holds  equally 
good  for  muscle  stimulation. 

"  Currents  of  very  high  duration  occasion  less  reaction  upon  muscu- 
lar tissue  than  upon  nerves ;  but  the  summation  of  the  individual  con- 
tractions produced  by  each  single  induction  stroke  results  in  tetanus,  as 
was  observed  in  the  excitation  of  nerves.  The  laws  of  muscular  contrac- 
tion produced  by  galvanism  are  analogous  to  those  already  formulated. 

"Depending  upon  the  strength  of  the  current,  living  muscles  it-act 
with  more  or  less  tetanic  contraction  to  faradisin,  and  with  single  con- 
tractions to  individual  contraction  currents.  This  occurs  so  much  more 
readily  the  nearer  the  electrodes  are  approximated  to  the  points  of 
entrance  of  the  motor  nerve-branches  into  the  muscle,  or  touch  these 
points  (motor  points)  directly. 

"The  galvanic  reaction  of  the  muscles  occurs  in  such  a  manner  that 
they  respond  to  stimulation  with  both  poles,  by  a  closure  contraction 
alone,  the  opening  contraction  being  absent,  or  obtained  very  excep- 
tionally. To  some  extent,  an  isolated  irritation  of  the  muscles  of  the 
body  by  the  galvanic  current  may  effect  a  local  galvanization,  founded 
upon  the  same  principles  and  methods  as  local  faradization.  Another 
very  important  group  of  effects  are  the  modifying,  irritability  changing, 
electrotonic  action,  which  are  manifest  in  the  electrical,  thermal,  or  me- 
chanical irritability  of  motor  nerves  (and  muscles)  during  the  passage 
and  after  the  cessation  of  the  current." 

ELECTROTOXUS. 

When  a  galvanic  current  is  passed  longitudinally  along  the  course 
of  a  motor  nerve,  the  nerve  changes  its  irritability  along  its  entire 
length,  which  is  especially  pronounced  in  the  vicinity  of  both  poles.  At 
the  cathode  and  its  vicinity  there  is  an  increase  in  the  electrical,  me- 
chanical, and  thermal  irritaltilit  \ .  and  that  portion  of  the  nerve  is  said 
to  be  in  a  state  «»f  ••  cateN-ct  lotoims  :  "  at  the  anode  and  its  vicinity  it  is 
decreased,  whence  the  term  ••  aneleetrotonns."  I  loth  increase  with  the 
duration  and  intensity  of  the  polari/.ing  current,  and  touch  one  another 


ELECTRO-PHYSIOLOGY.  95 

in  an  indifferent  point  of  the  intrapolar  region.  Upon  breaking  the 
current,  the  negative  modification  of  the  irritability  of  the  anode 
(anelectrotouus)  is  immediately  changed  to  a  marked  positive,  requiring 
some  time  for  its  disappearance  ;  at  the  cathode,  a  brief  negative  irri- 
tability rapidly  followed  by  a  vigorous  positive  modification,  with  an 
increase  of  irritability  which  gradually  returns  to  the  normal.  Thus 
after  breaking  the  current,  there  remains  a  normal  or  less  prolonged 
increase  of  irritability  at  both  poles. 

SENSORY  CUTANEOUS  XERVES. 

The  application  of  the  galvanic  current  to  the  skin  produces  a 
pricking  followed  by  a  burning  sensation,  which  may  increase,  and  cause 
intense  pain.  Possibly  these  sensations  may  in  a  large  measure  be  due 
to  the  effects  produced  by  the  chemical  substances  liberated  at  the  surface 
of  the  body  by  electrolysis  ;  many  asserting  that  the  reaction  of  the  sen- 
sory terminal  organs  is  not  identical  with  the  reaction  observed  in  the 
conducting  paths. 

The  sensory  irritations  appear  not  only  in  that  part  of  the  skin 
covered  by  the  active  electrode,  but  likewise  in  the  area  of  distribution 
of  that  nerve  or  nerves  lying  in  the  territory  of  the  electrode. 

SENSORY  XERVES  OF  MUSCLES. 

These  can  only  be  studied  satisfactorily  when  muscles  have  been  ex- 
posed by  wounds,  or  in  complete  anaesthesia  of  the  skin.  Every  vigorous 
muscular  contraction  is  accompanied  by  a  distinct  sensation,  which  has 
nothing  in  common  with  cutaneous  sensibility,  and  which  may  increase 
to  actual  pain  during  tetanic  contraction  (electro- muscular  sensibility). 
The  sensation  produced  is  in  direct  proportion  to  the  degree  of  muscular 
contraction,  and  is  usually  described  as  dull  and  tensile  ;  it  is  likewise 
produced  with  strong  galvanic  currents  as  soon  as  they  produce  tetanic 
m  uscular  contractions. 

UPON  THE  SPECIAL  SENSES. 

To  the  galvanic  current,  the  special  senses  respond  with  readiness  by 
means  <>f  their  specific  sensations,  the  latter  being  dependent  upon  the 
inlluence  of  both  poles.  The  optic  nerve  or  retina  reacts  quickly  to  the 
galvanic  current.  Pass  a  current  through  the  temples  or  cheeks  and 
upon  making  or  breaking  the  current  a  flash  of  light  will  appear.  Ap- 
ply a  stronger  current  some  distance  from  the  eye  (as  upon  the  neck  or 
chest  or  back),  and  the  same  phenomenon  resulting  illustrates  the  great 
sensitiveness  of  the  retina  to  galvanic  currents.  The  muscular  tissue  of 
the  iris  promptly  responds  to  the  faradic  current ;  even  the  pupillary 


96  ELECTKO-THERAPEUTICS. 

sphincter  can  be  made  to  contract  independently,  which  may  also  be 
accomplished  by  stimulation  of  the  motor  oculi  and  the  cervical 
sympathetic  nerves. 

The  auditory  nerve  being  very  deep  seated,  its  excitation  can  only 
be  effected  by  a  current  that  must  be  so  strong  as  to  product-  most 
unpleasant  associated  phenomena.  Galvanization  of  this  nerve  is  accom- 
plished by  placing  a  large  moist  sponge  electrode  immediately  in  front 
of  the  auditory  canal,  pressing  slightly  upon,  but  not  occluding  the 
tragus.  The  indifferent  electrode  is  placed  upon  the  back  of  the  n«-ck. 
The  strength  of  the  current  being  increased,  repeated  cathodal  closures, 
at  times  And,  are  made,  or  if  the  irritability  is  very  slight,  repeated 
changes  of  polarity  are  to  be  instituted.  The  normal  auditory  apparatus 
therefore,  only  gives  a  sensation  at  closure  upon  irritation  with  the  ("a, 
and  only  on  opening  upon  irritation  with  the  An.  Healthy  individuals 
usually  hear  sounds  described  as  whistling,  buzzing,  hissing,  or  roaring. 
The  AnO  reaction  is,  as  a  rule,  feeble  and  short.  By  an  increase  in 
the  strength  of  the  current,  the  auditory  sensations  increase  in  intensity. 
distinctness,  and  duration,  and  assume  a  more  musical  and  whistling 
character. 

By  the  galvanic  taste  is  meant  the  peculiar  acid,  salty  taste  which  is 
produced  by  placing  the  simplest  galvanic  element  (a  piece  of  zinc  and 
copper)  on  the  tongue,  or  by  passing  stronger  currents  through  the 
cheeks,  throat,  temples,  etc. 

If  two  medium  electrodes  be  placed  upon  the  cheek,  gustatory  sen- 
sations appear  at  both  poles.  The  sensation  is  more  marked  at  the  anode, 
where  it  is  metallic,  alkaline  or  perhaps  very  acid.  At  the  cathode  it 
is  milder,  biting  and  salty.  The  sensation  is  present  at  making,  breaking, 
and  during  the  passage  of  the  current. 

On  the  olfactory  nerve,  galvanic  stimulation  is  little  understood. 
By  some  it  is  said  to  produce  a  phosphorus- like  odor. 

UPON  THE  SYMPATHETIC  SYSTEM. 

The  study  of  the  galvanic  current  upon  the  sympathetic 
system  needs  to  be  further  prosecuted.  Physiologists  are  too  problem- 
atic in  their  deductions  as  to  the  functions  of  the  sympathetic  nerves 
and  their  interposed  ganglia,  to  lead  to  other  than  hypothetical  con- 
clusions. 

Faradization  of  the  cervical  sympathetic  causes  contraction  fol- 
lowed by  dilatation  of  the  vessels  of  the  corresponding  side  of  the 
head  and  face ;  slight  exophthalmos,  dilatation  of  the  opposite  pupil, 
and  an  accelerated  action  of  the  heart.  Galvanization  of  the  cervical 
sympathetic  is  much  slighter  and  less  certain. 

In  the  human  subject,  this  is  a  most  difficult  procedure.    The  cervical 


ELECTRO-PHYSIOLOGY.  97 

sympathetic,  being  very  deeply  situated,  has  in  its  close  proximity 
the  vagus,  the  carotid  with  its  vaso-iuotor  fibres,  the  base  of  the  braiii, 
the  cervical  region  of  the  cord,  etc. 

UPON  THE  SKIN. 

Galvanization  of  the  skin  will  first  produce  pricking  and  burning 
(as  detailed  under  its  action  on  the  sensory  cutaneous  nerves),  rapidly 
followed  by  an  intense  hyperaeinia  at  both  poles  ;  this  redness  may  remain 
for  hours,  and  be  marked  by  the  presence  of  papules  or  wheals,  and 
finally  succeeded  by  desquamation  of  the  epidermis. 

If  the  current  strength  be  augmented,  pallor  of  the  surface  is  noted 
at  t  he  cathode,  followed  by  a  rosy  redness  ;  the  skin  becomes  infiltrated 
and  surrounded  by  a  deep  border  ;  upon  opening  the  circuit  the  redness 
persists.  At  the  anode  a  pronounced  scarlatinal  color  appears,  the 
skin  is  not  infiltrated  but  covered  with  small  elevations ;  upon  opening 
the  circuit,  the  redness  persists  for  a  long  time,  and  is  followed  by 
desquamatiou. 

UPON  THE  HEAD. 

Vertigo  is  the  earliest  symptom  manifested  in  galvanization  of  the 
head,  when  a  strong  current  is  passed  transversely  or  in  the  antero- 
posterior  direction  (frontal  bone  to  the  back  of  the  neck).  The  giddiness 
is  most  pronounced  when  the  current  is  passed  transversely.  It  has  been 
maintained  by  some  observers  that  ocular  movements  play  a  dominant 
part  as  a  result  of  the  severe  vertigo,  and  that  there  is  a  disturbance  of 
the  muscular  sense.  With  a  strong  transverse  current  passed  through 
the  inastoid  processes,  oscillation  of  the  eyes  occurs,  the  direction  being 
that  of  the  positive  current.  If  the  anode  be  on  the  left  side,  both  eyes 
will  be  turned  to  the  right.  In  some  persons,  galvanization  of  the  head 
has  resulted  in  nausea,  vomiting,  syncope,  duluess  or  mental  confusion. 

UPON  THE  SPINAL  CORD. 

Large,  flat  electrodes  should  be  placed  upon  the  neck,  very  strong 
currents  should  be  employed,  and  closure  and  opening  should  be  resorted 
to.  If  the  negative  electrode  be  placed  on  the  upper  lumbar  vertebrae, 
CaCl  or  change  of  polarity  to  Ca  will  produce  vigorous  contractions  of 
the  muscles  supplied  by  the  sciatic  nerve,  proving  that  the  current  has 
invaded  the  cord. 

UPON  THE  ABDOMINAL  ORGANS. 

Vigorous  faradization  of  the  gall-bladder  in  cases  of  catarrhal  jaun- 
dice, has  caused  the  widely  contracted  gall-bladder  to  suffer  a  marked 

7 


98  ELECTRO-THERAPEUTICS. 

contraction.  Likewise  in  enlargements  of  the  spleen,  by  direct  faradi/a- 
tion  with  large  moist  electrodes,  or  by  employing  t\vo  faradic  brushes 
over  the  splenic  urea. 

The  pharynx  and  the  velum  palati  may  be  faradized  and  galvani/cd 
by  applying  the  positive  electrode  on  the  upper  posterior  part  of  the 
neck,  and  by  rapidly  passing  the  cathode  over  the  lateral  surface  of  the 
laryngeal  area.  Contraction  of  the  muscular  wall  of  the  esophagus  can 
be  obtained  by  introducing  electrodes,  similar  in  shape  to  oesophageal 
bougies. 

The  stomach  and  intestines  react  to  currents  by  slow  contractions, 
which  gradually  spreading  induces  a  peristaltic  action.  Faradism  is 
more  effective  in  these  cases  than  is  galvanism. 

Vigorous  faradization  of  the  abdomen  is  often  associated  with  a 
gurgling  sound,  and  with  the  production  of  visible,  palpable  peristaltic 
movements  of  the  stomach  and  intestines.  The  digestive  tract  may  be 
reached  by  one  electrode  placed  on  the  back,  the  other  stabile  or  slowly 
moving  over  the  corresponding  portion  of  the  abdominal  wall ;  or  by 
the  introduction  of  an  electrode  into  the  stomach  or  into  the  rectum,  the 
other  being  applied  labile  or  stabile  upon  the  external  abdominal  wall. 
Faradization  of  the  bladder  may  be  accomplished  by  introducing  a 
tirethral  electrode  as  far  as  the  vesical  neck.  Galvanic  currents  may 
likewise  be  employed.  The  contraction  of  the  vesical  sphincter  and  the 
urethral  muscles  is  readily  perceived. 

ELECTRICAL  CURRENTS  IN  DISEASES. 

This  is  a  most  complicated  process.  Remak  believed  (and  this 
view  still  obtains)  that  with  the  passage  of  the  current  there  results  a 
dilatation  of  the  blood-vessels  and  lymphatics,  causing  an  increased  flow 
of  blood  and  nutritive  material,  thereby  favoring  absorption  of  effete 
matter:  that  there. is  also  an  increased  osmotic  power  of  the  tissues, 
changes  in  disassimilation  and  nutrition  of  the  nerves,  changes  in  the 
molecular  arrangement  of  the  tissues  and  the  mechanical  transportation 
of  fluids  from  one  pole  to  the  other.  To  this  series  of  changes  the  name 
"catalysis"  is  applied. 


CHAPTER   VIII 
PEACTICAL  APPLICATIONS  IN  DISEASED  CONDITIONS. 

I.  Cutaneous  Affections. 

To  a  very  large  extent  electric  currents  have  been  employed  in  the 
treatment  of  skin  diseases,  and,  as  the  technic  differs  greatly  in  numerous 
cutaneous  affections,  it  seems  best  to  enumerate  the  various  skin  lesions, 
detailing  under  each  the  technic  that  seems  most  applicable. 

ACNE. 

In  this  affection  Liebig  and  Eohe  have  obtained  favorable  results. 
I  have  seen  a  few  cases  improve  by  the  use  of  hyperstatic  sparks,  and 
in  one  or  two  instances  by  the  ordinary  breeze. 

ECZEMA. 

The  local  effect  of  the  static  current  is  specially  indicated  in  eczema, 
where  the  brush  discharge  may  be  most  advantageously  employed. 
Eczema  yields  to  electrical  treatment  more  easily  than  any  other  skin 
lesion.  Eockwell  recommends  the  application  of  the  galvanic  current 
applied  either  locally  or  centrally.  Bordier  (quoted  by  Hedley)  reports 
a  case  of  eczema  thus  treated,  the  result  being  very  satisfactory.  He  uses 
the  positive  breeze,  and  this  frequently  reversed.  The  hydro-electric 
bath  has  given  very  satisfactory  results  in  the  practice  of  Gautier  and 
Laret. 

PRURITUS. 

In  pruritus  the  electric  breeze  is  most  useful.  The  duration  of  treat- 
ment should  be  between  fifteen  and  twenty  minutes.  The  metallic  point 
should  be  held  10  to  15  cm.  from  the  part. 

ALOPECIA. 

Local  galvanization  and  also  the  static  breeze  are  often  beneficial  in 
some  cases. 

SYCOSIS. 

M.  Boisseau  du  Rocher  employed  the  following  method  for  sycosis. 
Ten  to  fifteen  silver  needles  attached  to  the  positive  pole  are  inserted  into 
different  points,  the  indifferent  electrode  is  applied  to  the  nape  of  the 

99 


100  ELECTKO-THERAPEUTK  S. 

neck,  current  three  to  four  milliamperes,  duration  about  ten  minutes, 
application  every  second  day.  By  this  means  the  oxy-chloride  of  silver 
is  formed,  which  is  diffused  into  the  tissues  by  the  current.  It  may  take 
three  or  four  weeks,  and  20  to  30  seances,  to  complete  an  absolute  cure. 

HYPEETRICHOSIS. 

Since  we  are  able  to  cause  a  general  or  local  epilation  with  the 
X-rays,  the  process  of  electrolysis  is  gradually  being  abandoned.  The 
method  with  the  electric  needle,  formerly  so  prevalent,  but  tedious  and 
painful  in  operation,  has  largely  given  way  to  the  X-rays.  I  have 
succeeded  in  removing  hair  from  the  forearm  by  a  weak  but  constant 
current,  but  it  never  should  be  forgotten  that  an  acute  and  active  derma 
titis  may  thus  be  readily  produced.  If  the  hairs  are  few  in  number  and 
scattered  over  the  face,  I  believe  the  electric  needle  safer  and  less  dan- 
gerous though  more  painful  than  the  Rontgen  rays.  On  the  contrary,  a 
burn  with  the  X-rays  may  leave  a  life-long  scar.  For  the  face,  therefore, 
it  is  advisable  to  resort  to  electrolysis. 

The  method  of  epilation  is  as  follows  :  Place  the  patient  on  a  high 
chair,  take  a  fine  needle  which  is  attached  to  the  negative  pole  of  the 
galvanic  current,  while  the  patient  holds  the  positive  pole  in  the  hand. 
A  sponge  of  fair-sized  dimensions  and  well  wetted  is  attached  to  the  latin 
electrode.  The  number  of  cells  used  is  5  to  8,  so  that  a  current  of  from 
3  to  4  milliamperes  is  produced.  A  current  of  smaller  amperage  than 
this  may  be  used  ;  1  to  2  milliamperes  being  often  sufficient.  The  hair 
is  seized  with  a  pair  of  tweezers,  at  the  same  time  the  disengaged  hand 
inserts  the  needle  slowly  into  the  hair- follicle.  The  patient  squeezes  the 
sponge  to  complete  the  circuit,  which  is  indicated  by  small  bubbles 
emanating  from  the  point  where  the  needle  is  inserted.  The  needle  is 
usually  allowed  to  remain  10  to  15  seconds.  The  patient  now  loosens  the 
hold  so  as  to  break  the  circuit.  An  interrupting  handle  (Fig.  4(i)  is 


FIG.  46.—  Interrupting  needle-holder  for  electrolysis. 

employed  by  many  for  this  particular  purpose.  If  the  hairs  are  not 
loosened  readily,  defer  the  procedure  until  another  time.  The  needle 
should  be  heated  to  redness,  when  its  repeated  introduction  will 
be  necessary  for  each  individual  hair.  This  method  is  for  coarse  hair. 
For  the  downy  hair  seen  on  the  lip  or  chin  in  women,  this  method  is 
unsatisfactory,  and  it  is  advisable  to  resort  to  the  X-rays. 


APPLICATIONS  IN  DISKASHI)  COXDITIOXS.  101 

PSORIASIS  AND  PITYRIASIS. 

In  both  of  these  diseases,  the  negative  pole  of  the  galvanic  current 
seems  to  be  the  more  efficacious.  Sometimes  both  poles,  bearing  large 
electrodes,  are  employed. 

ElNGWORM    AND   SCLERODERMA. 

Both  of  these  diseases  are  markedly  improved  and  often  cured  by  the 
application  of  the  galvanic  current. 

PRURIGO. 

Dry  faradization  may  give  relief  from  the  intense  itching,  and  at 
times  will  effect  a  cure. 

CUTANEOUS  ANESTHESIA. 

For  this  condition  Rockwell  believes  faradization  to  be  a  specific. 
The  electric  brush  should  always  be  given  a  trial. 

HERPES  ZOSTER. 

Dr.  Larat 1  reports  several  cases  of  acute  herpes  zoster  in  the  erup- 
tive stage  with  fever  and  unbearable  lancinating  pains,  which  were  cured 
by  the  continuous  current.  The  method  is  simple  and  can  be  employed 
by  any  physician  owning  a  galvanic  battery.  The  positive  pole  (repre- 
sented by  an  electrode  3^  by  5  inches  [9  x  13  cm.],  covered  with  absorb- 
ent cotton  and  well  moistened)  is  applied  over  the  point  of  emergency 
of  the  affected  nerve  or  nerves.  The  negative  pole  is  connected  to 
an  electrode  placed  over  the  affected  area.  The  absorbent  cotton  cover- 
ing the  electrode  should  be  made  large  enough  to  cover  all  the1  vesicles, 
whether  formed  or  forming.  A  current  strength  of  from  6  to  10  ma.  is 
employed  for  25  or  30  minutes.  The  sensation  produced  by  this  current 
is  that  of  a  severe  pricking,  but  it  is  well  borne  by  the  patient. 

Two  applications  are  made  daily,  but  in  case  of  failure  at  first,  the 
author  recommends  that  more  be  used.  Under  their  influence  the  pain 
ceases,  the  eruption  is  arrested,  the  vesicles  show  a  tendency  to  dry  up, 
in  fact  all  the  local  manifestations  of  the  disease  appear  aborted.  A 
cure  is  accomplished  in  from  24  to  48  hours,  unattended  by  the  usual 
subsequent  neuralgia. 

The  probable  explanation  of  these  good  results,  is  the  accepted  hy- 
pothesis, that  herpes  zoster  is  a  trophic  and  sensory  peripheral  neuritis,  in 
which  the  continuous  current  has  the  same  curative  effects  as  are  manifest 
in  other  forms  of  peripheral  neuritis. 

1  Revue  Internationale  d'Electrotherapie,  October,  1904. 


102  KLFA  TIN  MTHERAPEUTK  \s. 

N.KVUS. 

Electric  treatment  should  be  instituted  ;us  soou  after  birth  as  is  prac- 
ticable. The  needles  may  be  alternately  negative  and  positive,  or  all 
attached  to  one  pole,  and  an  ordinary  pad  electrode  used  for  the  other 
pole.  Current  may  be  employed  up  to  30  ma.  Duration  5  minutes. 
Current  must  be  gradually  lowered  to  zero  before  withdrawing  the 
needles. 

PORT- WINE  MARK. 

For  these  disfigurements  use  a  number  of  needle-points  attached  to 
a  disk,  so  that  punctures  may  be  effected  simultaneously;  the  current  is 
gradually  turned  on,  allowing  2  to  3  ma.  for  each  needle.  This  proced- 
ure is  to  be  repeated  every  3  weeks.  The  needles  should  be  insulated, 
except  at  the  point.  The  pole  selected  will  vary  with  the  vascularity, 
the  prominence,  and  the  extent  of  the  uyevus.  With  large  blood  channels 
use  the  positive  pole;  for  flat  spots  some  of  the  needles  may  be  positive, 
some  negative.  Current  30  ina.  Duration  10  to  15  minutes.  The 
needles  are  left  in  place  half  a  minute,  so  as  to  produce  a  slight  eschar, 
they  are  then  shifted ;  the  whole  surface  being  thus  dealt  with. 

MOLES  AND  WARTS. 

The  indifferent  positive  electrode  is  placed  in  the  neighborhood  of 
the  growth.  A  needle  attached  to  the  cathode  is  inserted  at  its  middle, 
or  just  above  its  base,  parallel  to  the  integument.  Current  about  5  ma. 
Allow  the  current  to  flow  till  the  growth  changes  color  and  resembles  a 
cluster  of  herpes.  Then  bring  the  current  to  zero.  Time  required  is  2 
to  3  minutes  for  each  wart.  In  a  fortnight  the  growth  disappears, 
no  scar  remaining.  Another  method  is  to  attach  both  poles  to  sharp 
needles  and  transfix  the  growth  by  the  needles  inserted  parallel  to  the 
skin. 

FURUNCLES  AND  CARBUNCLES. 

The  local  treatment  of  these  growths  by  electricity  is  advocated  by 
Marcus.1  Previous  to  the  appearance  of  suppuration,  lie  opens  the  folli- 
cles of  the  affected  area  and  introduces  into  them  an  epilation  needle  con- 
nected with  the  negative  pole.  Through  this,  a  current  of  one  to  two 
milliamperes  is  passed  at  first,  which  is  afterwards  increased  to  ten.  By 
slightly  moving  the  needle  around,  the  opening  of  the  follicle  is  consider- 
ably enlarged,  and  a  quantity  of  frothy  serum  is  soon  poured  out.  con 
taining  portions  of  tissue  and  numerous  cocci.  Then  the  needle  is 
removed  and  the  spot  is  carefully  cleansed  ;  the  needle  is  again  introduced 

1  Miinchener  medizinische  Wochenschrift,  May  23, 1905,  No.  21. 


APPLICATIONS  IX  DISEASED  CONDITIONS. 


103 


aud  one  or  two  uiilliainperes  of  current  are  again  allowed  to  pass.  The 
positive  pole  is  now  to  be  connected  with  the  needle,  and  the  current  again 
raised  to  ten  milliauiperes.  This  causes  the  liberation  of  acid,  which  is 
always  more  energetic  in  its  nascent  condition.  In  two  or  three  minutes 
the  treatment  is  suspended  aud  the  surface  again  washed  with  water. 
Each  atfected  follicle  is  treated  in  the  same  manner.  If  suppuration 
has  already  commenced,  a  larger  needle  is  introduced  into  the  folli- 
cles and  moved  around,  until  the  entire  greenish-yellow  pus  plug  is 
broken  up  and  disappears  in  foam.  Then  the  positive  pole  is  intro- 
duced and  is  again  followed  by  the  negative  pole.  A  wet  dressing  is 
applied.  This  treatment  is  not  applicable  to  very  large  carbuncles  or 
extensive  swellings. 

II.  Muscular  System. 
MYALGIA. 

Employ  local  faradization  with  a  mild  current,  either  stabile  or 
labile.  Stabile  galvanization  with  a  mild  current  is  often  effective.  Do 
not  cease  if  .the  condition  is  unaffected  or  aggravated  at  first,  but  continue 
the  applications.  Static  electricity  by  means  of  a  roller  electrode  (Fig.  47) 
or  general  frauklinizatiou  is  frequently  curative. 


FIG.  47.— Roller  electrode  with  insulated  points  for  muscular  faradization. 

When  employing  the  battery,  Erb  advises  that  a  current  up  to  20 
ma.  may  be  used,  applying  the  anode  to  the  painful  parts,  and  the  seance 
terminated  by  a  few  reversals. 

General  electrization  by  means  of  the  nionopolar  sinusoidal  bath, 
faradic  current  applications,  and  static  friction  have  also  many  advocates. 

WRITERS'  CRAMP. 

It  is  assumed  that  this  disease  is  due  to  a  weakness  of  the  central 
nervous  system.  General  galvanization  of  the  spinal  column  and  pe- 
ripheral nerves  should  be  resorted  to.  Faradic  electricity  is  useful  when 
applied  directly  to  the  muscles  or  groups  of  muscles  of  the  hand  and 
forearm.  Seen  in  the  very  beginning,  its  course  is  often  arrested  by 
using  the  above  forms  of  electricity. 


104  ELECTKO-THERAPEUTICS. 

Weiss  l  recommends  the  use  of  constant  currents  of  2  to  5  or  8  ma. 
for  15  to  25  minutes,  with  absolute  rest  from  writing.  Applications 
twice  daily  should  be  employed  during  the  first  weeks,  diminishing  later 
to  2  or  3  times  a  week.  If  extension  is  the  chief  symptom,  the  anode  is 
to  be  applied  to  the  palm  ;  if  flexion  be  marked,  place  the  positive  pole 
to  the  dorsum  of  the  hand.  Apply  the  cathode  to  the  nape  of  the  neck 
or  the  upper,  inner  surface  of  the  arm  and  the  anode  to  the  sensitive 
parts  for  10  to  20  minutes.  Treatment  should  also  be  applied  to  the 
motor  cortex  and  to  the  lower  cervical  region  of  the  spine. 

TORTICOLLIS. 

In  torticollis  galvanization  of  the  muscles  of  the  affected  side  with 
currents  of  from  5  to  15  ma. ,  and  faradization  of  the  muscles  of  the 
opposite  side  often  prove  most  efficient.  Galvanization  of  the  sympa- 
thetic and  the  upper  portion  of  the  spinal  cord  should  always  be  tried ; 
but  long- continued  applications  are  contraindicated. 

MUSCULAR  CONTRACTIONS. 

These  may  arise  in  hysteria,  myelitis,  meningitis,  Pott's  disease,  or 
they  may  be  reflex.  These  affections  may  be  treated  by  galvanization  of 
the  affected  muscles  or  of  the  antagonistic  muscles  with  stabile  currents, 
or  by  galvanization  of  the  head,  spine,  or  sympathetic,  etc. 

SECONDARY  CONTRACTURES  OCCURRING  IN  HEMIPLEGIA. 

Charles  S.  Potts*  claims  that  in  cases  of  hemiplegia  where  con- 
tractures  have  been  allowed  to  develop,  the  patient's  disability  proceeds 
more  from  the  deformity  so  produced  than  from  muscular  weakness.  As 
the  deformity  is  caused  by  the  overaction  of  one  set  of  muscles,  usually 
the  flexors,  and  is  only  aggravated  by  their  stimulation,  the  indications 
are  for  measures  which  tend  to  relax  the  contracted  muscles.  This  can 
be  effected  by  the  application  of  the  positive  pole  of  a  galvanic  current 
over  the  motor  points  of  the  affected  muscles,  and  the  indifferent  elec- 
trode (negative  pole)  to  any  part  of  the  sound  limb,  as  over  the  sternum, 
or  to  the  nape  of  the  neck.  Anelectrotouus  should  be  aimed  at.  The 
current  employed  should  be  gradually  increased  from  0  to  5  or  10  milli- 
amperes  (about  as  much  as  the  patient  can  bear),  and  kept  at  this  maxi- 
mum for  five  minutes,  then  gradually  reduced  to  zero.  Unless  the 
current  is  gradually  reduced  to  zero,  catelectrotonus  will  follow  and  the 
condition  of  increased  irritability  thus  set  up  will  prevent  the  accomplish- 
ment of  our  object.  After  these  applications  of  a  continuous  current,  a 

1  Centralblatt  fur  die  gessam.  Therap.,  April,  1891. 

1  University  of  Pennsylvania  Medical  Bulletin,  October.  1905. 


APPLICATIONS  IN  DISEASED  CONDITIONS.  105 

weak  faradic  current  should  be  employed,  just  strong  enough  to  cause  the 
muscles  to  contract  moderately,  about  a  dozen  times  and  no  more,  as  over- 
stimulation  defeats  the  end  we  have  in  view.  The  method  is  also  of 
service  as  a  preventive  ;  it  may  be  started  any  time  after  the  end  of  the 
second  week  following  the  seizure.  Three  treatments  a  week  for  several 
months  should  be  given,  followed  by  an  interval  (several  weeks)  of  rest. 

MY  ASTHENIA  GRATIS. 

When  tetanized  by  the  interrupted  current,  the  myasthenic  muscle 
shows  a  rapid  decrease  in  the  degree  of  response  to  the  current,  evincing 
the  normal  physiological  effect  of  fatigue  with  excessive  and  abnormal 
rapidity  ;  but  after  tetanizatiou  it  remains  just  as  responsive  to  a  single 
closing  shock,  proving  that  the  muscle  is  not  diseased,  but  that  the 
trouble  resides  in  the  nervous  system. 

III.  The  Articular  System. 
SYNOVITIS. 

In  acute  synovitis  all  forms  of  electrical  applications  are  contraindi- 
cated.  Subacute  and  chronic  synovitis  will  be  benefited  by  galvaniza- 
tion or  faradization.  When  a  cure  cannot  be  effected  by  these  means, 
the  application  of  percussion  static  sparks  is  sometimes  effective. 

HYDRO-ARTHRITIS. 

In  the  acute  stage,  as  in  synovitis,  any  form  of  electricity  is  irritat- 
ing. In  the  subacute  and  chronic  forms  the  active  electrode  (negative) 
of  20  to  25  ma.  current  should  be  employed.  Each  treatment  should  last 
no  longer  than  10  to  15  minutes.  The  indifferent  electrode  is  placed  on 
the  back  of  the  patient.  The  treatments  should  be  made  on  alternate 
days,  or  every  third  day. 

EHEUMATOID  ARTHRITIS. 

In  this  affection  the  sinusoidal  bath  is  very  beneficial.  Dr.  Roques1 
treats  the  affected  joints  by  the  electrolytic  introduction  of  ions  of 
salicylic  acid  into  the  surrounding  tissues.  Many  electro-therapeutists 
believe  that  the  beneficent  action  thus  obtained  is  partially  ascribable  to 
a  nutritional  change  in  the  diseased  area. 

CHRONIC  ARTICULAR  RHEUMATISM. 

Chronic  or  subacute  articular  rheumatism  frequently  yields  to  static 
or  galvanic  treatment ;  with  the  former  it  subsides  gradually.  The 

1  Arch.  d'Electricite  medicale,  1903,  page  689. 


106  ELECTRO-THERAPEUTICS. 

condition  will  usually  be  benefited  by  local  faradization.  In  very  acute 
and  painful  cases,  it  is  well  to  resort  to  anesthetization  with  cocaine 
by  the  cataphoric  process. 

GOUT. 

This  disease  is  benefited  by  static  electricity.  This  stimulates  all 
the  tissues  of  the  part,  improving  the  circulation,  and  in  general  doing 
much  good.  The  continuous  flow  of  current  has  been  recommended,  but 
I  have  failed  to  obtain  any  appreciable  result  from  its  employment, 
Lithium  dipolar  baths  are  prescribed  by  some  authorities. 

Guilloz l  reports  two  severe  cases  of  gout  treated  by  monopolar  elec- 
tric baths  containing  lithium  carbonate.  He  recommends  currents  up 
to  200  ma. ,  and  places  the  positive  pole  in  the  bath,  the  cathode  of  large 
size  is  applied  to  the  patient's  back.  Similar  reports  by  Bordier,  in  the 
same  journal,  are  recorded. 

It  is  usually  maintained  that  the  various  currents  applied  directly  to 
the  joints  will  cause  a  stimulation  of  the  tissues  of  the  part,  resulting  in 
an  absorption  of  the  urates.  Prolonged  applications  may  aggravate  the 
condition. 

TUBERCULOUS  ARTHRITIS. 

Chanoz  and  LeVeque2  report  three  cases,  where  the  direct  current 
proved  of  inestimable  value  in  tuberculous  arthritis.  In  one  case  Leveque 
himself  was  the  sufferer,  and  his  treatment  directed  to  his  own  person 
was  eminently  satisfactory.  He  Relieves  that  the  negative  pole  is  effec- 
tive for  relieving  the  superficial  pain,  the  deeper  parts  being  more 
influenced  by  the  anode.  The  current  should  range  from  25  to  50  ma.  ; 
the  electrodes  should  be  of  large  size  and  placed  on  either  side  of  the 
diseased  joint. 

FIBROUS  ANKYLOSIS. 

Apply  large  electrodes  moistened  in  a  solution  of  sodium  chloride  to 
each  side  of  the  joint.  The  negative  pole  should  be  placed  nearest  the 
joint,  Use  a  current  strength  of  25  to  35  ma.  Duration  of  each  treat- 
incut  from  10  to  25  minutes.  Treatments  2  or  3  times  a  week.  These 
electric  treatments  should  be  instituted  only  when  there  is  no  inflamma- 
tory process  present. 

M.  A.  Zimmermann3  has  reviewed  the  medical  literature,  and  with 
the  exception  of  a  case  treated  by  Leduc,  of  ankylosis  of  the  elbow -joint 

1  Arch.d'£lectricite  mldicale,  June,  1899. 

2  Arch.  d'fclectricit£  m£dicale,  1903,  page  264. 
•Revue  Internationale  d'felectrotherapie,  October,  1904. 


APPLICATIONS  IX  DISKASKI)  <  OXD1TIOXS.  107 

reported  cured  by  electricity,  lie  has  found  nothing  on  the  subject.  Many 
surgeons  recommend  electricity  iu  such  cases  for  its  action  on  the  mus- 
cles surrounding  the  all'ected  joints,  but  that  is  a  form  of  electrical  mas- 
sage, and  not  an  electrical  application.  Zimmermaim  has  obtained  good 
results,  both  iu  hospital  and  private  practice,  in  cases  of  fibrous  anky- 
losis,  without  paiu  or  discomfort  to  the  patieut,  by  the  employment  of  the 
continuous  current.  It  is  of  importance  to  determine  the  nature  and 
severity  of  the  affection,  because  in  cases  of  bony  ankylosis  no  more 
good  is  accomplished  by  electricity  than  with  other  forms  of  treatment. 
However,  in  some  cases,  severe  fibrous  aukylosis  in  which  massage  and 
passive  motion  failed  to  afford  relief,  some  degree  of  mobility  was 
obtained ;  whereas  in  adhesions  resulting  from  a  gouorrhceal  or  other 
arthritis  or  from  prolonged  immobilization,  cures  were  speedily  attained. 
It  should  never  be  forgotten  that  radiographs  are  of  inestimable  value 
in  making  a  differential  diagnosis.  The  negative  electrode  should  be 
placed  over  the  most  superficial  part  of  the  diseased  joint,  and  the  posi- 
tive  electrode  on  the  part  of  the  joint  directly  opposite,  so  that  the  lines 
of  flux  will  pass  iu  a  straight  line  through  the  joint.  The  maximum 
intensity  should  be  at  least  40  ma. ,  and  the  applications  made  every  other 
day. 

The  number  of  applications  necessary  to  effect  a  cure  will  depend 
upon  the  severity  and  chrouicity  of  the  affection ;  from  15  to  20 
applications  are  required  in  cases  of  moderate  severity. 

IV.   Digestive  System. 
TOMITING. 

According  to  Apostoli  and  Bordier1  two  electrodes,  each  2  cm.  in 
diameter,  are  attached  to  the  positive  pole  of  the  battery,  and  .are  placed 
over  each  pneumogastric  nerve,  between  the  insertions  of  the  steruo-cleido- 
mastoid  muscle.  The  indifferent  electrode  (100  sq.  cm.)  is  placed  upon 
the  epigastric  region  attached  to  the  negative  pole.  The  strength  of 
current  should  be  from  5  to  10  milli amperes.  If  nausea  is  threatened, 
the  current  must  be  at  once  run  up  to  15  or  20  milliainperes  and  there 
maintained,  so  long  as  any  ill  effects  are  experienced  by  the  patient.  The 
duration  of  the  seance  varies  from  4  to  20  minutes.  Two  sittings  a  day 
may  be  required  at  the  beginning  of  the  treatment. 

DILATATION  OF  STOMACH. 

Dilatation  of  the  stomach  is  best  treated  by  the  static  induced  cur- 
rent. The  outer  cover  of  the  Leyden  jar  is  attached  to  an  ordinary 
exciter,  terminating  in  a  small  ball.  This  is  applied  over  the  uncovered 

1  Therapeutic  Electricity,  quoted  by  W.  S.  Hedley. 


108  ELECTRO-THERAPEUTICS. 

epigastric  region  ;  the  distance  of  the  pole  of  the  machine  should  be 
such  as  to  produce  sparks  at  the  rate  of  from  10  to  15  per  second.  The 
exciter  is  to  be  left  on  one  spot  for  a  couple  of  minutes,  then  displaced  to 
another,  and  so  on. 

The  duration  of  each  treatment  should  be  from  10  to  15  minutes ; 
the  usual  requisite  number  of  sittings  is  from  18  to  20,  which  should  be 
given  every  second  day. 

NERVOUS  DYSPEPSIA. 

For  this  affection  the  galvanic  current  does  most  good. 

The  negative  pole  is  usually  placed  over  the  epigastric  region  and 
the  positive  pole  opposite  the  lumbar  region.  The  strength  of  the  cur- 
rent should  be  from  30  to  40  milliamperes ;  the  duration  of  each  treat- 
ment should  be  from  10  to  15  minutes :  the  number  of  treatments  to  bring 
about  relief  is  from  8  to  10.  A  cure  cannot  be  effected  by  this  method 
of  treatment. 

CONSTIPATION. 

In  these  cases,  applications  over  the  cord  or  the  sympathetic  system 
frequently  produce  most  excellent  results.  Direct  action  on  the  digestive 
tract  is  often  advantageous  in  promoting  peristalsis. 

Method  of  Application. — The  patient  is  placed  on  the  insulated  plat- 
form, and  the  indirect  static  spark  is  applied  to  the  various  parts  of  the 
abdomen.  This  should  be  done  by  starting  in  the  right  iliac  or  inguinal 
region,  gradually  ascending  to  the  liver,  thence  across  the  upper  abdomen 
along  the  course  of  the  transverse  colon.  This  is  followed  by  descending 
to  the  left  side  of  the  belly  toward  the  upper  part  of  the  rectum.  The 
object  is  to  excite  peristalsis  in  the  normal  direction. 

The  galvanic  current  is  also  applied  for  this  condition,  but  in  my 
experience  the  results  obtained  are  not  so  satisfactory  as  with  static 
electricity.  A  large-sized  electrode  (100  sq.  cm.)  is  attached  to  the 
negative  pole  of  the  battery,  and  the  electrode  is  applied  to  the  belly  in 
a  similar  manner  as  outlined  above.  The  indifferent  positive  pole  is 
applied  to  the  lumbar  spine.  The  faradic  current  may  be  applied  instead 
of  the  galvanic. 

Dr.  Wahltnch1  has  reported  seven  cases  in  which  the  continuous 
current  produced  good  results.  He  used  a  large  sponge  for  the  positive 
pole  and  an  ordinary  medium-sized  one  for  the  negative.  The  former 
he  applied  to  the  epigastrium,  while  the  latter  was  slowly  moved  over 
the  whole  abdominal  surface.  The  current  was  from  5  to  30  milliamperes. 
The  operation  was  repeated  on  alternate  days,  from  three  to  six  weeks. 

'British  Medical  Journal,  1883,  vol.  11,  623. 


APPLICATIONS  IX  DISEASED  CONDITIONS.  109 

A  method,  which  lias  become  popular  in  France,  is  the  introdun  ion 
into  the  rectum  of  a  bougie  electrode,  the  other  pole  being  kept  ou  the 
abdomen.  To  avoid  the  risk  of  electrolysis,  and  injury  to  the  rectal 
mucous  membrane,  a  combined  douche  and  electrode  has  been  devised. 

ENTERITIS. 

Dr.  Zimmeru1  describes  the  excellent  results  he  had  obtained  in 
mucous  membranous  enteritis  by  the  use  of  the  galvanic  current  applied 
externally  to  the  abdomen.  The  treatment  consists  in  applying  the  two 
electrodes  in  the  right  and  left  iliac  fossae,  aud  using  a  current  which 
starting  from  0  is  slowly  aud  gradually  brought  up  from  GO  to  150  inil- 
liamperes,  then  as  slowly  again  reduced  to  0.  The  direction  of  the  cur- 
rent is  then  reversed.  Each  treatment  lasts  about  20  minutes,  and  is 
repeated  three  or  four  times  a  week.  No  special  attention  is  paid  to 
the  diet,  though  highly  spiced  food  is  of  course  forbidden.  All  enemas 
or  cathartics  are  strictly  prohibited,  save  with  the  following  exceptions. 
If  there  is  much  constipation,  two  spoonfuls  of  castor  oil  are  giveu  every 
five  days,  or  a  large  lavage  of  the  intestine  is  to  be  practised  if  the  castor 
oil  does  not  produce  the  desired  effect.  Every  day  a  very  small  enema 
of  cold  water  (100  grammes)  is  given  so  as  to  start  defecation  reflexly, 
which  is  more  or  less  dulled  by  the  lack  of  sensibility  of  the  mucous 
membrane. 

According  to  Zimmern,  the  results  obtained  are  not  so  much  due  to 
action  on  the  muscular  coating  of  the  intestine  as  to  action  on  the  general 
circulation  of  the  intestine.  Out  of  30  patients  treated  in  this  manner 
only  2  were  refractory  to  the  treatment,  and  20  were  absolutely  cured, 
the  remaining  eight  were  only  ameliorated.  Dr.  Delherm,  another 
specialist  in  this  line,  describes  the  results  obtained  by  the  galvauo-faradic 
treatment  in  53  patients :  46  cases  were  very  much  ameliorated  by  the 
treatment,  and  36  remained  cured  after  a  year. 

Rene  Desplats,  in  a  communication  to  the  Societe  des  Sciences  Medi- 
cales,1  stated  that  he  had  successfully  treated  twenty-five  cases  of  rnuco- 
membranous  colitis  and  spasmodic  constipation  by  electricity  of  high 
voltage. 

His  method  consists  in  placing  two  large  metallic  electrodes  (tin 
plates,  eight  by  ten  centimeters)  covered  with  several  double  folds  of 
buckskin,  moistened  with  warm  water,  upon  the  surface  of  the  abdomen, 
one  in  each  iliac  fossa,  and  passing  for  ten  minutes  a  current  of  sixty  to 
seventy  milliamperes.  a  little  more  or  less,  according  to  the  tolerance  of 
the  patient.  He  also  reverses  the  current  at  the  end  of  each  minute.  If 
the  sudden  reversal  causes  too  great  a  shock,  he  lowers  the  current  even 

1  La  Presse  Medicale,  No.  27. 

*  Journal  des  Sciences  Medicales  de  Lille,  April  14, 1906. 


110  ELECTRO-THERAPEUTICS. 

to  zero  before  reversal.  The  resort  to  all  purgative  remedies  is  suspended 
during  the  treatment  (which  is  repeated  every  t\vo  or  three  days),  but 
if  there  is  no  spontaneous  movement  by  the  third  day,  he  orders  an 
enema,  and  this  is  gradually  reduced.  In  atouic  constipation  the  results 
were  very  satisfactory,  even  iu  children. 

M.  W.  Peyser l  employs  a  short,  soft-rubber  rectal  tube  in  which  is 
placed  a  metallic  conductor;  this  is  passed  into  the  rectum,  coiling  in  the 
ampulla  being  prevented  if  possible.  The  metallic  conductor  is  attached 
to  the  positive  pole.  The  tube  is  connected  with  the  tube  of  a  fountain 
syringe  which  contains  saline  solution.  A  large  pad  electrode,  well 
moistened  with  saline  solution  or  thoroughly  soaped,  is  attached  to 
the  negative  pole.  While  the  solution  is  flowing,  or  after  the  syringe 
is  emptied,  the  current  is  turned  on  and  gradually  increased  in  strength 
till  from  15  ma.  to  20  ma.  are  passing,  or  till  the  patient  complains  of 
burning  at  the  negative  pole.  There  should  be  no  sensation  from  the 
current  at  the  positive  pole.  The  solution  in  the  bowel  acts  as  one  of  the 
terminals,  thus  spreading  the  current  over  a  large  extent  of  surface  and 
permitting  more  current  to  be  used.  Similarly,  the  large  pad  permits 
increased  amperage.  In  a  varying  period  of  time  desire  for  defecation 
conies  on — sometimes  immediately,  sometimes  not  for  several  hours. 
Should  it  come  immediately,  the  patient  should  be  persuaded  to  endeavor 
to  continue  the  treatment  for  a  while  longer.  The  number  of  treatments 
required  varies  from  six  to  ten,  rarely  less  than  the  former  or  more  than 
the  latter.  The  tolerance  of  the  patient  should  be  the  standard  as  to  the 
quantity  of  current,  some  taking  20  ma.  even  at  the  first  treatment, 
others  never  being  able  to  take  more  than  12  ma.  at  any.  The  time  of 
each  treatment  should  be  from  fifteen  to  twenty  minutes,  seldom  more, 
repeated  daily  till  positive  effects  are  obtained,  and  then  at  lengthening 
intervals  till  success  is  assured  or  failure  manifested. 

FISSURE  OF  THE  ANUS. 

The  indifferent  electrode  is  placed  upon  the  abdomen,  while  the 
anode,  covered  with  absorbent  cotton  saturated  with  a  10  per  cent  solution 
of  cocaine  (Massey),  is  applied  to  the  fissure,  using  a  1  to  5  ina.  current 
for  several  minutes. 

AFFECTIONS  OF  THE  RECTUM. 

In  paresis  of  the  sphincter  and  in  prolapse,  the  use  of  the  farad  ic 
current  has  produced  most  successful  results. 

Dr.  (}.  Bet  ton  Massey-  treated  a  case  of  rectal  prolapse  in  a  middle- 
aged  woman,  by  placing  a  felt-covered,  flat  electrode  under  the  sacrum  j 

1  Virginia  Medical  Semi-Monthly,  Feb.  9,  1906. 

2  Therapeutic  Electricity,  W.  S.  Hedley. 


APPLICATIONS  IX  DISEASED  CONDITIONS.  Ill 

the  patient  being  in  a  dorsal  position.  An  ordinary  rectal  electrode  was 
inserted  into  the  rectum,  connected  with  the  positive  pole.  With  the 
proper  regulation  of  the  current,  slow  interruptions  were  effected,  by 
touching  one  of  the  terminal  posts  with  the  tip  of  the  conducting  cord. 
This  produced  a  good  form  of  muscle  contraction.  Duration  10  minutes. 
No  prolapse  occurred  after  the  first  treatment. 

HEMORRHOIDS. 

The  treatment  of  internal  and  external  hemorrhoids  by  electricity  is 
by  no  means  easy.  I  have  never  seen  any  good  accomplished  by  this 
agent,  except  in  those  cases  where  the  electric  current  was  employed 
cataphorically.  Some  have  suggested  the  use  of  electric  needles,  and 
one  or  two  succeeded  in  obtaining  very  satisfactory  results.  The  electric 
cautery,  of  course,  is  a  method  for  the  relief  of  piles;  the  procedure  is 
rapid,  aseptic,  and  painless. 

STRICTURE  OF  THE  RECTUM. 

The  treatment  of  rectal  stricture  with  electricity  is  identical  with  that 
of  stricture  of  the  urethra.  The  instrument  used  is  larger  (Fig.  48),  and 


Km.  48. — Double  rectal  bulb  electrode. 

should  also  have  a  flat  surface  in  front  or  below.  The  indifferent  elec- 
trode should  be  held  by  the  patient's  hand,  or  it  may  be  applied  to  the 
anterior  abdominal  wall.  The  strength  of  the  galvanic  current  should  be 
from  5  to  15  millianiperes. 

V.   Genito-Urinary  System. 
STRICTURE  OF  THE  MALE  URETHRA. 

Crussel,  in  1839,  was  the  first  to  employ  electrolysis  for  the  cure  of 
stricture  of  the  urethra ;  Mallez  and  Tripier  were  the  first  to  practise  it 
systematically.1 

Dr.  \V.  E.  Stevenson 2  asserts  that :  The  electrodes  for  this  purpose 
arc  catheter-shaped  gum-elastic  bougies,  terminating  in  a  metal  nickel- 
plated  piece  connected  to  a  binding  screw  on  the  handle.  Place  the 
indifferent  electrode  on  the  patient's  back  ;  the  metal  plate  is  made 

'"De  la  guerison  durable  des   restrecissements  de  1'urethre  par  la  galvano- 
caustique  chimique,"  Paris,  lMi7. 

''Annual  Meeting  of  the  British  Medical  Association,  1886. 


112  ELECTRO-THERAPEUTICS. 

positive.  Estimate  the  distance  of  the  stricture  from  the  meat  us.  by 
marking  on  aii  ordinary  bougie  which  has  been  passed.  Suppose  this 
bougie  was  a  No.  3  (English).  A  No.  5  electrode  is  passed  down  to 
the  stricture,  where  it  is  arrested.  Corroborate  this  by  previously  mark- 
ing the  electrode,  corresponding  to  the  mark  made  on  the  bougie.  Place 
the  electrode  again  in  position,  connect  it  with  the  negative  pole  ;  the 
circuit  is  closed,  aud  the  current  gradually  increased  without  breaks, 
until  the  maximum  strength  is  reached,  about  5  or  0  milliamperes.  The 
electrode  is  gently  pressed  against  the  stricture  in  the  normal  direction 
of  the  urethra  until,  from  the  dissolution  of  the  obstacle  in  front  of  it, 
it  passes  into  the  bladder.  The  current  should  at  once  be  cut  oft',  and 
the  bougie  withdrawn. 

The  late  Dr.  Robert  Newman,  of  New  York  City,  advocated  the 
following  :  The  patient  is  placed  in  the  dorsal  position,  the  thorax, 
abdomen  and  lower  extremities  being  in  one  horizontal  line,  while  the 
head  of  the  patient  is  slightly  elevated  by  raising  the  head-rest  of  the 
table.  A  large  electrode  in  the  terminal,  on  the  positive  side  of  the 
battery,  is  placed  over  the  abdomen  in  a  fixed  position,  and  well  pressed 
upon  the  tissues,  so  as  to  make  a  perfect  circuit. 

The  negative  electrode,  in  the  form  of  a  whalebone  bougie,  has  at 
the  inner  extremity  an  olive-shaped  head  of  the  proper  size.  This  is 
introduced  into  the  urethra  as  carefully  as  possible.  The  current  is  then 
turned  on  with  the  lever  of  the  rheostat,  so  as  to  prevent  shocking  the 
patient. 

The  galvanic  current  that  is  used  usually  varies  between  three  aud 
five  milliamperes.  The  treatments  should  last  for  a  period  of  from  10  to 
15  minutes.  Two  of  these  treatments  are  essential  to  start  with,  then 
discontinue  for  another  period  of  two  days  or  two  weeks,  according  to 
the  indication.  Care  should  be  exercised  to  pass  through  the  lumen  of 
the  stricture  a  bougie  of  very  little  larger  dimensions  than  that  of  the 
calibre  of  the  opening.  At  the  second  treatment  a  bougie  with  a 
metallic  ovoid  should  be  passed,  the  dimensions  of  it  being  slightly  larger 
than  that  used  primarily.  By  doing  this,  there  is  a  gradual  dilatation  of 
the  lumen.  After  two  weeks  a  bougie  of  little  longer  dimensions  should 
be  employed,  and  exactly  the  same  process  carried  out  as  outlined  above. 
The  treatment  should  consume  a  little  more  time,  and  the  current  used 
should  be  5  milliamperes.  The  third  treatment  should  be  given  on  the 
16th  day,  the  fourth  on  the  19th,  and  so  on.  The  operator  should  always 
remember  that  in  active  inflammation  of  the  urethral  tract,  elect  i  it- 
applications  are  contraindicated. 

After  the  dilatation  of  the  stricture,1  Selhorst  inserts  an  Ober- 
laender's  urethroscopic  tube,  passing  along  the  whole  length  of  the 

1  British  Med.  Journal,  March  24,  1906. 


APPLICATIONS  IN  DISEASED  CONDITIONS.  113 

stricture.  In  examining  the  urethra,  the  tube  is  withdrawn  slowly  until 
the  surface  of  the  constriction  is  shown  in  the  opening.  The  needle, 
ending  in  a  strong  platinum  point  from  1.5  cm.  to  2  cm.  in  length,  iso- 
lated quite  close  to  its  point,  is  forced  to  a  depth  of  from  0.5  cm.  to 
1  cm.  into  the  fibrous  tissue,  according  to  the  dimension,  thickness,  and 
hardness  of  the  stricture.  The  needle  is  the  negative  pole  of  a  galvanic 
battery,  the  positive  pole  of  which,  a  large  moistened  disk,  is  placed 
on  the  thigh  or  on  the  abdomen.  The  electric  current,  of  from  4  to  6 
inilliamperes,  is  turned  on  for  three  minutes.  Before  withdrawing 
the  needle  Selhorst  interrupts  the  current,  and  drives  the  needle  into 
another  part.  This  operation  may  be  repeated  four  or  five  times  during 
a  sitting,  and  if  executed  by  an  expert  hand,  is  said  not  to  be  very  pain- 
ful. During  the  whole  period  of  treatment  a  bougie  is  introduced  once 
weekly,  followed  by  an  irrigation  with  a  nitrate  of  silver  solution  to  pro- 
mote reabsorptiou,  and  to  maintain  the  passage  of  the  urethra  at  the  size 
required. 

Philippe1  credits  electrolysis  with  many  cures  of  simple  stricture, 
but  maintains  that  a  combination  therewith  of  lavage  with  carbonic  acid 
is  required  when  chronic  urethral  inflammation  exists  as  a  complication. 
He  records  excellent  results  in  varicose  ulcers,  torpid  wounds,  fistula,  etc. 
The  gas  is  heated  to  45°  C.  and  driven  into  the  urethra  under  a  pressure 
that  may  be  regulated.  It  is  saturated  with  essence  of  cinnamon  as  an 
antiseptic  agent.  Miuet  and  Aversenq  use  rigid  bougies  with  a  mercury 
bisulphate  battery.  A  current  of  3  to  4  milliamperes  is  passed  for  a 
period  of  15  minutes,  once  weekly.  This  treatment  is  preceded  by 
progressive  dilatation  with  ordinary  sounds,  but  the  permanent  results 
are  mainly  attributed  to  the  electrolysis. 

PROSTATITIS. 

This  condition  may  be  treated  with  local  faradization  or  galvaniza- 
tion. One  of  the  poles  is  applied  to  the  urethra  or  to  the  prostate 
through  an  insulated  sound  or  catheter.  The  other  electrode  is  in  the 
form  of  an  insulated  rectal  sound.  The  terminal  of  the  electrode  passed 
into  the  urethra  is  of  course  allowed  to  remain  uncovered,  as  it  is  to 
come  indirectly  in  contact  with  the  prostate.  The  current  should  be  of 
such  a  strength  as  to  produce  a  sensation  of  warmth  in  the  deep  urethra. 

Dr.  John  V.  Shoemaker,2  of  Philadelphia,  has  devised  an  electrode 
which  is  well  adapted  to  prostatic  work.  The  instrument  (Fig.  49)  is  for 
use  in  the  reduction  of  hypertrophy  of  the  prostate  by  means  of  the  gal- 
vanic current  from  the  negative  pole.  The  usual  flexible  rheophores  are 

1  La  Presse  Medicale,  May  11,  1904. 
'The  Times-Register,  January  17,  1891. 


114  ELECTKO-THEKAPEUTICS. 

attached  to  the  terminal  binding  posts  (the  negative  pole  of  the  battery 
being  associated  with  the  handle  X,  and  the  positive  pole  with  the  handle 
P).  The  reophores  having  been  thus  previously  fastened,  the  rectal  limb 
of  the  instrument  (which  has  a  movement  in  the  vertical  plane)  is  pressed 
down  toward  the  sponge -covered  moistened  pole  ;  the  olive-shaped  bulb 
pole,  B,  having  been  previously  slightly  oiled.  The  instrument  is  then, 
with  the  handle  X  held  in  the  rear,  passed  under  the  crotch.  The  cur- 
rent of  the  battery  is  supposed  to  have  been  previously  set  flowing. 
Grasping  then  the  rear  handle,  N,  with  the  right  hand,  and  allowing  the 
front  handle,  P,  to  fall  away  from  the  crotch,  the  patient  now  presses  the 
olive-shaped  bulb,  B,  gently  into  the  rectum;  any  slight  error  of  judg- 
ment as  to  direction  being  compensated  for  by  the  movement  of  that 
limb  in  the  vertical  plane.  The  patient  then  grasps  the  front  handle, 


FIG.  49.— Shoemaker's  prostatic  electrolyzer. 

P,  and  raises  the  lever  formed  by  the  hinges,  H,  thus  bringing  the  mois- 
tened sponge-covered  positive  pole,  S,  in  contact  with  the  perineum.  By 
exercising  more  or  less  pressure  with  this  pole  against  the  perineum,  the 
current  is  then  regulated  to  the  greatest  nicety  by  the  patient's 
sensations. 

The  resistance  to  the  current  varies  from  25,000  to  30,000  ohms,  the 
milliamperemeter  indicating  from  2  to  3  milliamperes,  the  duration  of 
administration  being,  according  to  Dr.  Shoemaker  and  other  authorities, 
from  3  to  5  minutes. 

PARALYSIS  OF  THE  URINARY  BLADDER. 

The  electrical  treatment  for  paralysis  of  the  bladder  is  divided  into 
the  internal  and  the  external.  The  currents  employed  are  both  the  gal- 
vanic ami  faradie.  Some  suggest  the  use  of  the  static  current,  but  in  my 
experience  this  has  accomplished  little  good. 


APPLICATIONS  IN   DISEASED  CONDITIONS.  115 

The  external  application  is  conducted  by  placing  the  negative  pole 
or  electrode  over  the  symphysis  pnbis,  and  the  positive  to  the  back  of 
the  neck. 

The  internal  application  can  be  made  by  placing  the  insulated  cathe- 
ter clt-d  rode  or  Diichenue's  double  vesical  electrode  into  the  urethral 
tract.  Tlu1  negative  pole  of  the  battery  is  attached  to  the  leader  in  the 
rubber  catheter,  while  the  positive  pole  is  applied  to  the  hypogastric 
region,  or  back  of  the  spine. 

INVONTIXKNVE  OF  URINE. 

This  condition  is  treated  electrically,  as  in  paralysis  of  the  bladder. 
In  the  adult,  both  the  internal  and  external  methods  may  be  employed. 
In  children  the  external  method  alone  is  usually  used. 

Faradic  treatment  is  to  be  preferred  in  cases  of  children  and 
especially  in  those  who  have  had  incontinence  from  earliest  infancy.  Of 
40  subjects,  55  per  cent,  were  cured  by  Genoiiville  and  Compain  ;l  63  per 
cent,  of  the  children  were  between  6  and  12  years  old.  The  sittings 
numbered  from  5  to  8  in  congenital  cases,  and  in  nou- congenital  cases 
from  6  to  16  treatments,  with  the  exception  of  5  patients,  who  had  20  to 
29  seances.  Slight  improvement  during  the  first  week  is  a  favorable 
sign.  The  current  may  be  applied  directly  to  the  sphincter  or  to  that 
immediate  region.  All  but  20  per  cent,  of  the  subjects  were  improved 
or  cured,  and  in  16  cases  a  complete  recovery  occurred  in  a  maximum  of 
16  visits. 

Xociurnal  Incontinence. — In  this  affection,  the  application  of  elec- 
tricity stimulates  the  cerebral  and  spinal  centres,  by  producing  painful 
local  impressions,  which  tend  to  bring  the  inhibitory  cerebral  mechanism 
into  closer  relation  with  the  reflex  centres  in  the  lumbar  cord.  For 
women  and  older  girls,  a  bare  metal  sound  is  introduced  into  the  urethra 
as  one  electrode,  the  indifferent  electrode  being  placed  upon  the  lower 
dorsal  spine.  The  sound  must  not  enter  the  bladder  for  more  than  a 
short  distance,  or  else  the  current  will  pass  to  the  urethral  walls.  For 
male  patients  the  applications  can  be  made  to  the  perineum. 

SPERMATORRHOEA  AND  SEMINAL  EMISSIONS. 

These  conditions  can  be  treated  either  by  the  application  of  local 
or  general  galvanic  or  faradic  currents,  either  internal  or  external.  The 
internal  method  consists  of  introducing  an  electrode,  insulated  by  a  rub- 
ber catheter,  into  the  urethral  tract,  as  outlined  in  cases  of  prostatitis. 
In  the  treatment  of  vesiculitis  or  ordinary  spermatorrho?a,  care  must  be 
exercised  to  cause  as  little  irritation  internally  as  possible.  The  results 

1  La  Presse  Mt'dicale,  1904,  No.  38. 


116  ELECTRO-THERAPEUTICS. 

obtained  are  due  to  the  electrolytic  action  on  the  mucous  membrane,  as  a 
result  of  the  mechanical  pressure  of  the  catheter,  or  upon  a  combination 
of  these  two  factors.  Sparks  and  the  static  breeze  to  the  perineum,  also 
the  brush  discharge  over  the  lumbar  and  sacral  vertebrae,  may  prove 
useful  in  some  of  these  cases. 

IMPOTENCE. 

If  this  condition  is  the  result  of  an  organic  lesion,  electricity 
will  do  little  good  ;  on  the  other  hand,  benefit  may  be  gained  by  the  use 
of  the  static  breeze,  spark,  etc.  Cases  of  impoteucy  due  to  a  psychical 
influence  may  likewise  be  improved  by  the  use  of  electricity. 

ORCHITIS. 

Scharff1  employed  electricity  successfully  in  the  treatment  of  epi- 
didymitis.  During  the  acute  stage  he  applies  the  anode  to  the  lower 
part  of  the  scrotum  with  the  patient  in  the  dorsal  position,  employing  a 
large  electrode  with  a  maximum  current  of  half  a  millianipere  ;  dura- 
tion of  the  first  application  three  minutes ;  very  gradually  increased  to 
five,  and  later  to  ten  minutes.  About  the  seventh  day  the  current  can 
be  increased  to  three  millianiperes.  The  cathode  is  placed  over  the 
groin  and  on  the  abdominal  wall.  The  advantages  of  this  treatment 
are  its  rapidity,  and  the  early  relief  from  pain  and  swelling.  Good 
results  have  been  obtained  by  Ouimus  and  Duboc,  of  Rouen  ; 2  Picot,  of 
Tours,  has  succeeded  in  forty  cases. 

NEPHRITIS. 

Rockwell  reports  five  cases  of  nephritis  treated  by  electricity,  four 
of  which  recovered.  Treatment  covered  a  period  of  from  two  to  eighteen 
months  ;  after  a  few  months  osdema  and  ascites  disappeared. 

The  technic  of  treatment  consists  in  the  employment  of  a  high-ten- 
sion faradic  current,  and  also  the  use  of  the  static  wave  current,  the 
latter  being  the  more  preferable.  He  suggests  that  these  currents  should 
be  employed  alternately. 

VI.  The  Nervous  System. 
NEURALGIA. 

Electricity  is  applied  to  neuralgia  in  the  following  forms  : 

General  faradization  and  central  galvanization. 

Local  faradization  or  galvanization. 

Central  and  peripheral,  or  a  combination  of  both. 

'Centralbl.  f.  Krankh.  d.  Harn  und  Sex.  Organe,  1,  1894. 
»Arch.  d'fclectricifcS  medicale,  1894. 


APPLICATIONS  IN  DISEASED  CONDITIONS.  117 

Galvanization  of  the  cervical  sympathetic. 

Cataphoresis. 

The  sinusoidal  current. 

Electric  brush. 

Electric  moxa. 

Static  electricity. 

Electric  bauds  and  disks. 

The  magnet. 

The  initial  applications  should  be  mild,  owing  to  the  pain  frequently 
becoming  intensified,  especially  after  prolonged  sittings.  The  applica- 
tions should  be  made  daily,  or  every  other  day.  Either  the  positive  or 
negative  pole  may  be  applied  over  the  painful  points.  There  is  no  rule 
for  the  direction  of  the  current.  The  duration  of  the  seance  should  be 
brief. 

Should  the  faradic  current  be  tried  without  effect,  resort  should  be 
made  to  the  galvanic  current,  or  the  two  may  be  used  alternately.  Cen- 
tral and  general  galvanization  are  to  be  conducted  on  general  principles. 
Cataphoresis  will  at  times  benefit,  when  other  methods  fail.  The 
sinusoidal  current  often  acts  most  happily.  The  electric  moxa  is  some- 
times  efficacious,  but  its  use  is  attended  with  great  pain.  It  acts  partly 
as  a  counter-irritant. 

Cephahdgia. — Dry  faradization  with  the  hand  is  most  useful  in  many 
forms  of  headache.  Stabile  galvanization  or  faradization,  uniform  or 
increasing,  may  be  used.  General  faradization  is  more  effective  than 
local  applications.  Central  galvanization  is  at  times  the  only  effective 
measure. 

Tic  Douloureux. — In  this  exquisitely  painful  condition,  peripheral 
galvanization  or  faradization  should  be  tried  ;  the  electric  moxa,  or  gal- 
vanization of  the  brain  or  cervical  sympathetic,  has  in  some  cases  proved 
effective. 

Professor  S.  Leduc,  of  Nantes,1  reported  several  cases  in  which  he 
had  obtained  excellent  results  in  neuralgia  by  the  electrolytic  intro- 
duction of  salicylic  ions  (galvanic  Cataphoresis).  Recently  he  has  again 
resorted  to  this  method  with  success  in  a  case  of  tic  douloureux  of  thirty- 
five  years'  standing.  This  patient  was  cured,  according  to  Dr.  Leduc, 
in  three  seances  by  salicylic  ionizatiou.  The  method  followed  was  to 
apply  the  cathode,  moistened  with  a  solution  of  sodium  salicylate, 
to  the  right  side  of  the  face,  and  at  the  first  treatment  the  current 
was  raised  gradually  to  an  intensity  of  45  milliamperes  and  maintained 
there  for  forty  minutes.  After  the  second  stance,  which  took  place 
three  days  later  (when  the  current  was  allowed  to  pass  for  one  hour, 
with  a  current  of  35  milliamperes),  he  experienced  decided  ameliora- 

1  La  Semaine  Medicale,  November  22,  1905. 


118  BLBCTBO-THBBAPBUTIOS. 

timi.  Finally,  a  third  and  last  ionizatiou,  of  forty  minutes,  brought 
about  a  final  cessation  of  the  pain.  The  pain  now  only  returns  during 
exposure  to  cold. 

r<  ripheral  Neuralgia. — Whatever  the  cause,  these  cases  should  IK; 
treated  by  stabile  Eradication  and  galvanization,  or  the  electric  inoxa. 
lu  rebellious  cases,  central  and  general  electrization  should  be  tried. 

Sciatica. — Faradization  is  to  be  recommended  in  this  condition.  For 
the  novice,  galvanization  is  to  be  preferred,  owing  to  the  extreme 
evenness  of  the  current  required.  Au  ill-directed,  prolonged  current 
often  aggravates  the  condition.  I  have  had  good  results  with  the  static 
spark. 

PARALYSIS. 

Rheumatic  Paralysis. — In  these  cases  faradization  is  extremely  useful. 
The  electro-muscular  contractility  in  recent  cases  is  normal,  in  long- 
standing cases  diminished.  It  is  important  to  institute  treatment  before 
the  occurrence  of  muscular  atrophy.  Static  and  galvanic  electricity  are 
also  valuable  in  rheumatic  paralysis. 

Syphilitic  paralysis  is  treated  in  a  manner  similar  to  rheumatic  pa- 
ralysis. 

Lead  Paralysis. — In  this  affection  the  electro- muscular  sensibility  is 
diminished  and  frequently  lost,  and  diplegic  contractions  may  appear.  If 
the  electro-muscular  contractility  is  completely  lost,  apply  a  galvanic  cur- 
rent, 5  to  15  ma.,  to  the  paralyzed  part  before  the  faradic  current  is 
employed.  The  latter  current  should  be  used  daily,  10  to  15  minutes  at 
each  sitting.  When  the  slightest  contractions  occur  from  the  faradic 
current,  the  galvanic  may  be  discontinued. 

Paralysis  from  opium,  stramonium,  arsenic,  etc.,  is  to  be  treated  by 
general  faradization. 

Hemiplegia. — Treatment  should  not  be  commenced  until  four  or  five 
weeks  after  the  attack.  Vigorous  electrization  of  the  affected  limbs  may 
completely  restore  them.  Further  efforts  may  be  directed  to  the  cranial 
lesion  by  the  application  of  the  continuous  current.  The  anode  is  applied 
to  the  forehead  and  to  the  sides  of  the  head,  the  cathode  to  the  nape  of 
the  neck  ;  the  former  electrode  being  moved  slowly  to  and  fro  without 
interruptions.  Current  strength  1  to  5  ma.  The  active  electrode  should 
be  of  medium  size.  Daily  treatments  for  one  month  ;  duration  of  each 
sitting,  5  minutes.  If  aphasia  be  associated,  the  anode  may  be  applied 
to  the  third  left  frontal  convolution.  I  prefer  the  static  breeze  over  the 
head,  with  indirect  sparks  to  the  affected  side. 

Paraplegia. — Early  in  the  disease  the  galvanic  and  the  faradic  reac- 
tions may  be  normal.  Where  the  posterior  columns  arc  a  fleeted,  electro- 
amesthesia  may  likewise  coexist.  Treatment  consists  in  galvanization  or 


APPLICATIONS  IN  DISEASED  CONDITIONS.  119 

faradization.  The  electro-muscular  contractility  is  frequently  so  much 
diminished  that  it  becomes  necessary  to  give  particular  attention  to  the 
motor  points  in  order  to  produce  contractions. 

I'dcitil  Paralyxix. — Facial  paralysis  should  be  treated  by  local  faradi- 
zation and  galvanization.  When  response  is  not  obtained  by  the  faradic 
current,  it  is  of  little  use  to  employ  it ;  it  being  far  better  to  depend 
upon  the  galvanic  current.  In  this  disease  the  current- re verser  electrode 
is  exceedingly  convenient.  A  current  just  sufficient  to  produce  contrac- 
tion is  better  than  a  stronger  current,  and  short  applications  are 
preferable  to  long  ones. 

Poliomyelitis. — In  poliomyelitis,  the  paralysis  precedes  the  wasting. 
The  faradic  irritability  soon  becomes  lost,  with  temporary  increase  of 
galvanic  irritability  and  degenerative  reactions.  The  latter  are  often 
mixed,  due  to  the  nerve-fibres  being  unequally  affected,  an  increase  of  gal- 
vanic irritability  in  the  muscles  with  retention  of  faradic  irritability  in 
the  nerve.  In  infantile  palsy,  there  is  loss  or  absence  of  electro- muscular 
contractility.  Treatment  consists  in  the  galvanization  and  faradization 
of  the  affected  muscles,  and  the  constitutional  methods  of  treatment  of 
general  faradization,  central  galvanization,  and  static  electrification. 

Locomotor  Ataxia.  — The  electro -muscular  contractility  may  be  normal 
or  increased,  as  distinguished  from  ordinary  motor  paralysis,  depending 
upon  anterior  or  lateral  spinal  sclerosis.  It  may,  however,  be  dimin- 
ished. The  disease  may  be  treated  by  galvanization  of  the  spine,  central 
galvanization,  and  general  faradization,  when  cerebral  disturbances  or 
general  ataxia  of  the  nervous  system  appear,  galvanization  of  the  cer- 
vical sympathetic  and  peripheral  faradization  with  sponges  and  the 
metallic  brush.  Static  electricity  by  means  of  long  percussive  sparks 
over  the  spine  is  often  useful. 

CHRONIC  SPINAL  MUSCULAR  ATROPHY. 

The  use  of  central  galvanization  is  here  indicated,  with  faradization 
and  galvanization  of  the  affected  muscles.  Static  electricity  is  strongly 
commended  by  many  electro-therapeutists. 

EPILEPSY. 

Erb  recommends  the  following  method  :  u  Place  the  anode  over  the 
forehead,  and  the  cathode  to  the  neck.  Current  1  to  2£  milliamperes. 
The  duration  of  each  treatment  is  about  one  minute.  The  position  of 
the  electrode  is  then  changed  ;  the  anode  is  then  placed  to  the  middle  line 
of  the  head  and  the  cathode  to  the  occiput." 

I  advise  the  administration  of  the  static  current ;  especially  the  wave 
current  or  breeze  over  the  head,  has  in  some  cases  done  good.  The  cur- 
rent should  be  applied  every  day,  if  possible,  and  continued  for  months. 


120  ELECTROTHERAPEUTICS. 

INSOMNIA. 

This  affection  frequently  yields  to  treatment  by  electricity.  I  have 
seen  patients  fall  into  sleep  while  I  was  treating  them  with  the  static 
breeze.  The  galvanic  current  applied  to  the  sympathetic  system,  or  the 
faradic  current  applied  to  the  head  and  spine,  and  also  general  farad  i/a- 
tion  have  given  most  encouraging  results.  The  majority  of  electro- 
therapeutists  incline  to  the  opinion  that  the  most  favorable  results  are 
attained  by  employing  the  static  current. 

HYSTERIA. 

In  this  condition  a  psychical  effect  is  produced  by  the  static 
and  also  by  the  galvanic  current.  It  is  also  possible  in  many  cases  that 
a  lessening  of  nervous  irritability  results  from  the  electrical  applica- 
tions. In  fact  very  little,  if  any,  good  is  done  in  this  disease  by  the  use 
of  electricity. 

HYPOCHONDRIASIS  AND  MELANCHOLIA. 

In  these  conditions  both  general  galvanization  and  faradization  of 
the  cervical  sympathetic  do  good  by  the  psychical  effect  upon  the  patient. 
Static  electricity  in  some  cases  would  appear  to  be  beneficial. 

INSANITY. 

The  various  forms  of  insanity  are  at  times  favorably  influenced 
by  using  the  same  treatments  as  are  referred  to  in  the  preceding  para- 
graph. It  is  unfortunate  that  in  asylums  electricity  has  not  been  more 
extensively  employed.  The  use  of  the  static  bath  would  seem  to  be 
beneficial,  and  to  this  end  experiments  are  being  conducted  at  the  Phila- 
delphia Hospital. 

NEURASTHENIA. 

Dr.  Charles  K.  Mills !  believes  that  electricity  used  only  in  the  form 
of  general  faradization,  with  a  slowly  interrupted  current,  is  less  useful 
than  massage.  In  not  a  few  cases,  the  nurse  who  attempts  to  give  faradic 
electricity  to  a  patient  is  unskilful  or  irritating  in  her  method  of  admin- 
ist ration.  On  the  whole.  Mills  prefers  the  method  of  direct  muscular 
faradization,  supplemented  with  gliding  or  labile  currents,  applied  to  the 
entire  limb  or  part.  The  nurse  holds  two  moistened  electrodes  in  one 
hand,  and  passes  from  one  muscle  to  another ;  then  placing  one  elec- 
trode to  the  spine  or  in  the  neighborhood  of  the  nerve  plexus,  the 
electrode  is  passed  from  point  to  point  down  the  limb. 

1  Transactions  of  the  Philadelphia  County  Medical  Society,  Nov.  29,  1905. 


APPLICATIONS  IN  DISEASED  CONDITIONS.  121 

Dr.  W.  B.  Snow1  says  in  reference  to  the  electrical  treatment  <>f 
neurasthenia:  '"  For  the  general  tonic  effects  indicated  in  every  case  of 
neurasthenia,  the  wave  current  should  be  administered,  by  placing  the 
long,  spinal  electrode  (one  inch  in  width  and  18  to  22  inches  in 
length)  over  the  vertebral  column  from  the  cervical  to  the  lumbar  iv- 
gioii  for  from  at  least  15  to  20  minutes,  and  employing  as  long  a  spark- 
gap  as  may  be  used  without  causing  uncomfortable  muscular  contractions. 

••Patients  will  usually  take  a  treatment  with  a  four-inch  spark. 
Though  persons  with  small  muscles  and  but  little  fat  may  not  bear  a  two- 
inch  spark-gap  current,  large  or  fat  persons  will  bear  and  require  one 
measured  by  a  five-  or  six-inch  spark  discharge.  After  the  first  few 
applications,  the  patient  perspires  gently  with  each  such  treatment 
Not  only  does  the  activity  of  sweat  glands  resume,  but  there  is  a  grad- 
ually increasing  resumption  of  other  functions.  There  is  marked  in- 
crease in  the  daily  excretion  of  solids  in  the  urine,  digestion  improves, 
appetite  returns,  the  bowels  become  more  regular. 

•  •  While  many  cases  have  been  cured  by  no  other  agency  than  the 
wave  current,  we  believe  that  the  active  peripheral  stimulation  and  mas- 
sage afforded  by  the  long  and  friction  sparks  hasten  the  recovery  of  every 
case,  the  time  factor  of  which  will  depend  on  the  duration  of  the  affec- 
tion, the  adherence  to  regimen,  the  extent  of  functional  derangement, 
the  recuperative  powers  of  the  patient,  the  regularity  with  which  the 
treatments  are  administered,  and  the  technic  employed.  Treatment 
should  be  given  daily  for  at  least  two  weeks,  when  every  second  day  may 
suffice." 

EXOPHTHALMIC  GOITRE. 

In  the  treatment  of  exophthalmic  goitre,  Dr.  Francis  B.  Bishop,2  of 
Washington,  believes  that  the  only  rational  method  of  procedure  is  by 
means  of  the  electric  current. 

The  vagus  is  easily  stimulated  in  the  neck  from  the  subauricular 
fossa  to  the  clavicle,  and  with  a  much  weaker  stimulus  and  in  much  less 
time  than  the  sympathetic.  So  with  care  we  may  get  the  inhibitory  and 
other  influences  of  the  vagus,  without  unduly  exciting  the  sympathetic. 

Preference  for  the  application  to  the  vagus,  has  been  for  the 
continuous  current,  and  the  method  of  application  has  been  to  stimulate 
both  nerves  at  the  same  time.  A  large  sponge-electrode,  attached  to  the 
positive  pole,  is  placed  high  up  on  the  back  of  the  neck.  A  bifurcated 
cord  is  used  for  the  negative  side,  and  two  small  sponge-electrodes  are 
placed  one  on  each  side  over  the  pneumogastric,  in  the  lower  part  of  the 
neck  and  impinging  upon  the  thyroid. 

1  Poet-Graduate,  December,  1900. 

2  The  Journal  of  Advanced  Therapeutics,  February,  1904. 


l_>i>  KLECTRO-THKRAPHTTK  S. 

"The  current  is  gradually  turned  on  and  the  pulse  noted,"  says 
Bishop;  "the  current  is  allowed  to  remain  at  that  point  for  ten  or  fifteen 
minutes,  or  longer,  until  a  decidedly  quieting  effect  has  been  produced. 
Then  the  small  sponges  are  placed  directly  on  the  gland  and  the  current 
turned  on  to  the  point  of  tolerance,  and  is  allowed  to  pass  from  five  to 
eight  minutes.  This  treatment  is  persisted  in  every  other  day.  and  in 
many  cases  a  decided  improvement  will  be  noticed  in  a  month.  Later, 
I  have  been  using  the  high-potential,  high-frequency  current  as  an 
auxiliary,  and  have  been  much  pleased.  One  patient  begged  me  to  dis- 
continue all  other  treatment,  as  she  was  so  much  benefited  by  the  high- 
frequency  spark  applied  directly  to  the  thyroid  and  cervical  spine,  over 
the  liver,  spleen,  kidneys,  abdomen,  and  over  the  region  of  the  ovaries. 
A  letter  received  some  time  ago  states  that  she  continues  to  improve." 

Heiimau's1  experiences  with  electro-chemical  treatment  of  exophthal- 
mic goitre  encourage  further  work  in  this  line,  he  thinks.  He  applies 
the  cathode  over  the  goitre  with  the  continuous  current,  25  to  40  milliam- 
peres,  similar  to  Bordier's  tehnic,  except  that  he  uses  a  cathode  which 
contains  potassium  iodide.  In  one  case,  for  instance,  he  applied  a  cur- 
rent of  20  niilliamperes  for  about  twenty  minutes  a  day,  the  positive 
electrode  on  the  back,  and  the  negative  on  the  neck.  The  cathode  was 
placed  on  a  thin  sheet  of  lead,  shaped  to  the  neck,  over  several  layers  of 
sterile  gauze  impregnated  with  a  concentrated  solution  of  potassium 
iodide,  covering  the  entire  goitre.  The  current  was  turned  on  and  off 
very  gradually.  After  a  week  of  this  treatment  all  the  symptoms  of  the 
exophthalmic  goitre  had  disappeared,  and  the  size  of  the  neck  had  been 
reduced  from  39.5  cm.  to  38  cm.  The  patient  felt  perfectly  well  and  has 
continued  in  good  health  since  that  time — November,  1905.  The  im- 
provement in  another  case  described  was  almost  equally  striking,  and  in 
this  case  iodide  was  found  in  the  urine  five  days  after  the  last  appli- 
cation. He  also  detected  iodine  in  gauze  under  the  anode  of  the  back. 
Other  cases  from  his  experience  are  described  and  some  of  the  laws  of 
electro-chemistry  are  cited  to  explain  the  phenomena  observed. 

VII.  Gynecology. 

The  value  of  electro- therapeutic  measures  in  gynecology  has  been 
for  many  years  a  subject  of  heated  discussion  among  its  many  champions, 
and  among  the  equally  numerous  opponents  to  its  employment  in  diseases 
peculiar  to  women. 

Dr.  Barton  Cook  Hirst,'  of  Philadelphia,  remarks  that  of  late  he 
has  found  galvanism  and  faradism  of  value  in  a  limited  number  of 

1  Hygieia,  Stockholm,  La>t  Iii«l»«x,  p.  903. 

1  "Limitations  and  Possibilities  in  the  Treatment  of  Diseases  of  Women,"  read 
before  the  Philadelphia  County  Medical  Society,  January  25,  15)05. 


APPLICATIONS  IN  DISEASED  CONDITIONS.  123 

conditions  in  gynecological  practice.  As  a  liiemostatic  in  uncomplicated 
vSinall  fibroid  tumors,  with  no  other  symptom  than  metrorrhagia,  he 
regarded  it  as  a  most  efficient  agent.  He  found  it  peculiarly  useful  in 
the  treatment  of  amenorrlKua  and  sterility,  the  results  of  imperfect 
development  or  atrophy  of  the  uterus.  Two  illustrative  cases  were 
reported  in  which  normal  menstruation  was  restored  and  conception 
occurred  after  the  use  of  this  treatment.  In  one  woman  there  had  been 
amenorrho3a  for  a  year.  In  the  other,  the  menstruation  had  been  reduced 
to  a  scanty  discharge  lasting  less  than  a  day,  as  a  result  of  lactation 
atrophy.  The  third  indication  was  to  restore  tone  to  a  paretic  sphincter 
aui  muscle,  after  its  imperfect  restoration  by  surgical  means,  in  which 
there  had  been  no  contractile  power  exercised  for  a  number  of  years.  A 


FIG.  50.    Vesical  electrode,  for  hydro-electric  application  to  female  bladder.    Useful  in  atony,  dila- 
tation, chronic  cystitis,  etc. 


FIG.  51. — Goelet's  iutra-uteriue  electrode,  with  interchangeable  tips. 

fourth  indication  was  found  in  certain  types  of  dysmeuorrhoea  associated 
with  an  ill-developed  uterus.  Local  treatment,  however,  he  believed, 
was  very  rarely  practicable  in  such  cases. 

In  disease  of  the  uterus,  local,  central,  and  general  treatment  may  be 
employed.  Local  treatment  may  be  external  or  internal. 

The  uterus  and  the  appendages  may  be  treated  electrically  by 
applying  one  pole  over  the  hypogastrium  and  the  other  over  the  lumbar 
region.  In  virgins  this  method  should  always  be  tried  first. 

In  the  internal  method,  one  pole  may  be  applied  to  the  os  by  means 
of  an  insulated  electrode  with  a  metallic  belt,  while  the  other,  bearing  a 
broad  electrode,  is  applied  to  the  back,  or  on  the  hypogastric  region,  or 
over  an  ovary. 

In  using  the  faradic  current,  both  poles  are  applied  internally.  The 
sinusoidal  current  is  of  great  value  for  the  alleviation  of  uterine  pain. 
Figs.  50  and  51  illustrate  two  valuable  electrodes  in  gynecological  work. 


li'  4  ELECTKO-THEKAPEUTICS. 

AMEXORRHCEA. 

For  ameuorrho3a  Dr.  Golding  Bird1  believes  in  the  value  of  shocks 
from  the  Leydeii  jar.  He  transmits  twelve  successive  shocks,  from  the 
sacrum  to  the  pubes.  Panecki  uses  the  induction  coil.  In  chlorosis, 
marked  benefit  is  said  to  accrue  from  the  nutritional  effects  of  the  electric 
bath.  In  healthy  women  who  menstruate  regularly,  electricity  often 
hastens  the  flow,  especially  when  applied  to  the  abdomen  or  pelvic  re- 
gion. Another  method  consists  in  having  the  patient  lie  on  a  large  elec- 
trode, and  in  applying  a  circular  one  with  the  handle  alternately  to  the 
epigastrium  and  hypogastrium,  stabile,  using  30  millianiperes.  This 
should  l>e  succeeded  by  a  strong  primary  faradic  current. 


When  this  affection  is  due  to  a  cervical  stenosis,  electrolysis  is  indi- 
cated. For  dysmenorrhrea,  independent  of  stenosis  or  structural  change, 
the  galvanic  current  is  of  value  in  relieving  congestion  and  pain.  The 
applications  are  to  be  made  prior  to  menstruation  and  repeated  daily. 
These  same  applications  offer  most  beneficial  results  in  dysnieuorrhoea 
dependent  upon  pelvic  cellulitis  ;  occasionally  the  faradic  current  is  of 
value. 

FIBROID  TUMORS. 

The  electrical  treatment  of  uterine  fibromata  has  been  elaborately 
studied  by  Bartholow,  Massey,  Engelmauu,  and  many  others.  Indeed 
since  the  brilliant  investigations  by  Apostoli,  the  literature  of  uterine 
fibromata  has  assumed  massive  proportions.  In  1882  Apostoli,  in  an  arti- 
cle to  the  Academic  de  M6decine,  expounded  his  views  on  a  subject  here- 
tofore unthought  of,  that  at  once  aroused  attention  and  invited  thought. 
He  advised  the  use  of  an  internal  platinum  positive  electrode,  and  an 
abdominal  negative  electrode,  of  large  surface,  made  of  moist  china  clay, 
with  a  continuous  current  of  60  to  70  milliamperes.  Applications  5  to 
15  minutes.  Stances  once  or  twice  weekly.  The  current  was  to  destroy 
the  mucous  membrane,  which  was  succeeded  by  a  healthy  repair  process 
and  by  a  cicatrization  to  check  the  metrorrhagia. 

Bergonie  and  Boursier2  sum  up  the  results  they  obtained  in  one  hun- 
dred cases  of  uterine  fibroids  as  follows:  "The  electric  treatment  of 
fibro-myomata  is  undoubtedly  efficacious  as  a  palliative  method  of  treat- 
ment. When  hemorrhage  was  the  chief  symptom  complained  of,  90  per 
cent,  were  relieved.  The  general  state  of  health  was  improved  in  79  per 
cent.;  the  pain  was  relieved  in  50  per  cent.,  while  a  decrease  in  the  size 
of  the  tumor  was  observed  in  10  per  cent,  only." 

'Electricity  and  Magnetism,  1840,  Lecture  V,  and  Appendix  B. 
7  Arch,  d'Etectricit.'  in.-dicale,  1893.  L'l  1. 


APPLICATIONS  IN  DISEASED  CONDITIONS.  125 

OVARIAN  TUMORS. 

The  electrolytic  treatment  of  these  tumors,  which  was  formerly  so 
largely  in  vogue,  has  been  completely  abandoned  by  electro-therapeutists. 
The  danger  incident  upon  operation  is  less  than  that  incurred  by 
electrolytic  means. 

CHRONIC  METRITTS. 

In  these  cases  either  the  faradic  or  galvanic  current  may  be  used. 
The  more  usual  method  is  to  apply  the  galvanic  current.  Place  the 
anode  (per  speculum)  upon  the  os,  and  the  cathode  upon  the  epigastrium, 
stabile  5  to  10  minutes,  2  or  3  times  a  week.  Current  about  20  milli- 
amperes. 

PERIUTERINE  H.EMATOCELE. 

Apostoli's  method  is  intended  to  effect  a  chemical  caustic  change  by 
means  of  the  cathode.  A  fistula  is  thus  established,  which  tends  to 
remain  open,  with  adhesions  between  the  seat  of  the  affection  and  the 
external  mucous  membrane. 

STENOSIS  OF  THE  CERVICAL  CANAL. 

In  these  cases  galvanism  is  of  great  value.  Introduce  a  sound,  con- 
nect it  with  the  cathode,  apply  the  anode  to  the  abdomen.  Current  50  to 
75  milliamperes  ;  application  5  minutes. 

SUBINVOLUTION   AND    ATROPHY. 

Early  in  the  condition,  the  faradic  current  is  most  useful,  applied  by 
means  of  the  bipolar  electrode.  Later  in  the  affection  the  galvanic  cur- 
rent is  to  be  employed,  and  the  treatment  to  be  instituted  is  similar  to 
that  for  chronic  metritis. 

URETHRAL  CARUNCLE. 

If  pedunculated  the  galvano-cautery  snare  is  passed  around  the 
caruncle  and  the  current  turned  on.  The  carbon  or  platinum  electrode 
is  used,  covered  with  absorbent  cotton  saturated  in  a  solution  of  cocaine. 
Current  5  to  15  milliamperes.  When  no  pedicle  exists,  puncture  with  a 
negative  needle  ;  current  10  to  15  milliamperes. 

POST-PARTUM  HEMORRHAGE. 

Use  current  of  the  primary  wire  with  an  inter-uterine  electrode,  with 
the  indifferent  electrode  on  the  abdomen.  A  pocket  faradic  battery 
answers  admirably,  that  of  Gaiffe  of  Paris  being  deservedly  popular. 


1L'(5  ELECTRO-THERAPEUTICS. 

VOMITING  OF  PREGNANCY. 

In  vomiting  of  pregnancy  the  induction  coil  of  fine  wire  is  preferably 
employed.  Apply  the  anode  to  the  nape  of  the  neck,  the  cathode  to  the 
epigastrium.  Avoid  the  uterine  region. 

SLOW  LABOR. 

This  may  be  hastened,  and  atony  and  inertia  of  the  uterus  overcome 
by  the  use  of  the  faradic  current.  Electrodes  of  large  size  are  applied 
on  each  side  of  the  fimdus,  near  the  umbilicus.  A  powerful  current  is 
passed  with  the  occurrence  of  a  pain. 

Dr.  C.  A.  Covell,  in  a  paper  entitled  "A  Case  of  Asthma  with  Fi- 
broids and  Pelvic  Adhesions  Cured  by  Galvanism,'1  '  mentions  the  case  of 
a  patient,  aged  37,  married,  who  suffered  with  marked  dysmeuorrhoea  and 
bearing-down  pains.  The  pelvic  trouble  became  constant,  and  she  was 
advised  to  undergo  an  operation  for  hysterectomy  and  ovariotomy.  The 
author  then  says,  "  because  of  the  great  tenderness  and  pain  I  used  the 
vaginal  abdominal  alternations,  a  large  pad  of  absorbent  cotton  and  wire 
being  placed  over  the  abdomen  and  a  Leclanche  zinc  insulated  with  rub- 
ber tubing,  the  tip  covered  by  cotton,  was  placed  in  the  vagina.  Gradu- 
ally turning  the  current  on  and  off,  and  reversing  it  occasionally,  from  25 
to  100  milliauiperes  were  used,  she  being  able  to  bear  more  current  .sonic 
days  than  at  others.  Treatments  were  given  at  first  every  other  day  and 
later  twice  a  week  only.  Improvement  was  rapid.  In  six  mouths  the 
exudate  was  absorbed,  and  in  one  year  the  pelvic  organs  were  nearly 
normal.  The  fibroids  were  reduced  to  the  size  of  a  walnut.  The  pain 
ceased,  and  as  the  pelvis  cleared  the  asthma  became  less  and  less,  finally 
ceasing  also. 

"I  did  not  see  her  again  professionally  for  four  years.  One 
year  since  she  became  pregnant,  without  any  unusual  symptoms.  She 
went  to  full  term,  and  in  May  last  was  delivered  at  the  Good  Shep- 
herd Hospital  of  a  nine- pound  boy.  Labor  lasted  five  hours  and  was 
normal  in  all  respects.  While  she  was  under  chloroform  I  carefully 
examined  the  uterus  and  found  two  interstitial  fibroids  the  size  of  my 
thumb. 

uTo  me  the  interesting  things  about  this  case  are  these  :  The  asthma 
was  of  reflex  origin  and  ceased  as  the  pelvic  condition  was  relieved. 

"The  method  of  application  of  the  current  in  periuterine  inflam- 
mation. 

"The  uterus,  which  the  leading  gynecologist  of  central  New  York 
said  it  was  necessary  to  remove  to  save  the  patient's  life,  under  elec- 
trical treatment  prodnc«-«l  fi.nr  years  later  a  healthy  child." 

1  Read  at  the  Thirteenth  Annual  Meeting  of  the  American  Electro- Therapeutic 
Association,  Atlantic  City,  .September  23,  1903. 


APPLICATIONS  IX  DISEASED  CONDITIONS.  r_>7 

VIII.  Aneurism. 

Treatment  of  aneurism  by  electro- puncture  dates  back  to  Prava/, 
(IS.'iX),  Peterkin  (.  IS45),  and  Ciniselli  (1870). 

Ciniselli '  lias  collected  23  cases  of  aneurism,  six  of  which  were  appar- 
ent ly  cured  by  electro- puncture,  16  died,  and  in  one  case  result  is  not 
known.  The  operators  sometimes  used  one  needle  in  the  sac,  sometimes 
both.  Tripier  advocates  the  insertion  of  the  positive  needle  only,  on 
account  of  its  property  of  coagulating  albumen.  In  Ciuiselli's  cases,  20 
to  10  cells  were  used  from  10  to  30  minutes.  The  method  now  frequently 
employed  is  to  take  a  fine  coiled  wire  of  gold,  silver,  or  platinum,  so  drawn 
out  that  it  may  be  readily  passed  through  a  thoroughly  insulated  needle. 
The  anode  is  the  active  electrode,  the  cathode,  a  clay  pad  on  the  abdomen. 
The  current  may  gradually  ascend  to  80  milliamperes.  Duration  30  to 
(JO  minutes. 

Cornelius  A.  Griffith2  describes  an  interesting  case  of  sacculated 
aneurism  of  the  abdominal  aorta,  treated  by  the  introduction  of  silver 
wire  and  the  passage  of  the  constant  current. 

The  tumor  was  in  the  epigastric  region,  lying  almost  directly  to  the 
left  of  the  middle  line,  extending  up  under  the  ribs  and  downward  nearly 
to  the  umbilicus,  its  size  being  about  that  of  a  cocoanut ;  it  caused  some 
bulging  of  the  epigastrium,  was  distinctly  pulsating,  and  presented  a 
well-marked  systolic  bruit.  Pain  was  constantly  present  in  the  back 
and  at  the  left  side,  and  also  in  the  epigastrium,  following  the  taking 
of  food  ;  occasional  retching  was  experienced,  but  there  was  no  actual 
vomiting. 

Subsequently  an  operation  was  determined  upon,  when  a  fine,  long, 
metal  trocar  and  canula  were  thrust  well  into  the  sac,  the  trocar  was 
withdrawn,  and  a  vulcanite  insulating  canula  substituted,  through  which 
fine  silver  wire  was  introduced  into  the  sac.  About  six  feet  of  wire  were 
passed  in,  connected  to  the  negative  pole  of  a  constant  current  battery, 
and  15  to  25  milliamperes  passed  for  15  minutes.  At  the  end  of  this 
time  it  was  noticed  that  the  tumor  was  harder  and  the  pulsations 
had  grown  less.  The  cauula  was  then  withdrawn  and  the  operation 
completed,  whereupon  it  was  noticed  that  the  bulging  caused  by  the 
tumor  had  almost  disappeared.  Patient  died  in  about  five  hours, 
apparently  from  shock.  Port-niortem  examination  showed  that  the 
sac  was  filled  with  a  dark  clot  about  the  coiled  wire,  and  that  a  double 
loop  of  the  wire  had  been  passed  for  about  two  inches  up  into  the 
thoracic  aorta.  The  introduction  of  coils  of  wire  in  aneurismal  sacs 

1  Lnigi  Ciniselli  ("Sugli  aneurism!  dell'  aorta  toracica  finora  trattati  colla  elletro- 
puntura  ") ,  Milliano,  1870,  quoted  in  Dr.  Reyes's  paper  on  "  Practical  Electro-Therapeu- 
tics," New  York  Med.  Journal,  Dec.  1871. 

2  London  Lancet,  August  12,  1905. 


128  ELECTRO-THERAPEUTICS. 

should  be  avoided  if  possible,  and  the  immediate  clotting  of  the  blood 
within  the  sac  by  the  passage  of  a  small  current  is  believed  to  be  of 
advantage. 

Dr.  H.  A.  Hare1  reported  eight  operations  of  this  nature,  the  three 
now  reported,  making  a  total  of  eleven,  in  his  own  experience. 

The  first  of  these  three  cases  occurred  in  a  woman  of  50,  the  aneu- 
rism involving  the  superior  and  posterior  portions  of  the  transverse  arch 
of  the  aorta,  and  included  the  origin  of  the  large  vessels  arising  from  this 
part  of  the  aorta.  The  occurrence  of  severe  symptoms  made  relief 
imperative,  and  gold  wire  to  the  amount  of  eight  feet  was  passed  into  the 
sac  through  an  ordinary  insulated  needle,  and  through  this  wire  was 
passed  an  electrical  current  started  at  5  milliamperes  and  gradually 
increased  to  50  milliamperes  for  30  minutes.  The  immediate  effect  of 
the  operation  was  to  relieve  the  pressure  symptoms,  and  for  several 
weeks  afterward  she  was  able  to  sleep  in  a  reclining  posture  with  perfect 
comfort.  Six  months  later  the  growth  began  to  enlarge  at  the  margin  of 
the  clot,  and  death  finally  occurred  from  pressure  and  exhaustion. 
Autopsy  confirmed  the  diagnosis  in  every  particular,  and  revealed  the 
wire  embedded  in  the  clot. 

The  second  case  occurred  in  a  man  aged  42,  and  was  probably  trace- 
able to  heavy  lifting.  There  was  some  paralysis  of  the  right  vocal  cord, 
but  no  interference  with  swallowing  ;  the  growth  filled  the  epiclavimlar 
space  at  the  right  side,  and  passed  backward  under  the  steruo-mastoid 
muscle,  pushing  apart  the  bellies  of  the  two  branches  of  this  muscle 
and  protruding  prominently  into  this  space.  Two  feet  of  gold  wire  were 
passed  into  the  tumor  and  the  current  passed  as  before,  from  5  to  50 
milliamperes  being  used  in  the  course  of  40  minutes.  The  patient  was 
relieved  immediately  after  the  operation,  and  his  voice,  to  some  extent, 
soon  returned.  Four  months  later,  however,  he  died  from  exhaustion  and 
pressure.  Autopsy  confirmed  the  diagnosis,  but,  strangely  enough,  no 
trace  of  the  wire  could  be  found  in  any  part  of  the  clot. 

The  third  case  occurred  in  a  woman  aged  50,  and  involved  the 
thoracic  aorta  just  below  its  descending  portion.  Erosion  of  the  ribs 
was  noted  upon  the  left  side,  so  that  the  sac  projected  to  the  extent  of 
two  inches  outside  of  the  line  of  the  body  between  the  vertebrae  and  the 
lower  third  of  the  left  scapula.  Nine  feet  of  wire  were  introduced  and 
the  current  passed  as  in  the  preceding  case,  from  5  to  50  ma.  during  a 
period  of  three-quarters  of  an  hour.  The  immediate  effect  of  the  opera- 
tion was  to  diminish  the  expansile  pulsation.  At  the  end  of  four  mouths, 
however,  the  patient  died  from  pressure  symptoms  and  exhaustion.  The 
autopsy  confirmed  the  diagnosis  and  revealed  the  wire  embedded  in  the 
centre  of  the  clot. 

1  Therapeutic  Gazette,  July  25,  1905. 


FIG.  52.— Ozone  inhalation.  The  generator  should  be  suspended  to  within  a  few  inches  from 
the  mouth  of  the  patient,  and  attached  to  the  positive  pole  of  the  machine.  The  patient  is  placed 
upon  an  insulated  platform  connected  with  the  negative  pole.  The  oxygen  of  the  air  confined  within 
the  globe  is  broken  up,  forming  ozone,  by  the  convective  discharge  of  the  current  passing  from  the 
numerous  points  of  the  brush  within.  It  is  of  paramount  value  where  sprays  or  medicated  vapors 
cannot  reach  the  part  by  other  means. 


CHAPTER   IX 
APPLICATIONS   IN   THE   SPECIALTIES. 

I.  Rhinology  and  Laryngology. 
ATROPHIC  EHINITIS.  t 

IN  atrophic  rhinitis,  Delavan1  suggests  the  application  of  the  nega- 
tive pole  to  the  retro-nasal  space,  and  the  positive  pole  to  the  nape  of  the 
neck.  The  strength  of  the  galvanic  or  faradic  current  should  be  from  4 
to  0  milliamperes.  Each  treatment  should  last  from  5  to  12  minutes.  The 
applications  should  be  made  every  other  day. 

PHARYNGITIS. 

Hahn 2  asserts  that  he  obtained  good  results  in  cases  of  pharyngitis 
by  the  use  of  the  faradic  current.  Violet  rays  and  high-frequency  cur- 
rents have  frequently  proved  useful.  In  pharyngitis,  and  in  many 
pharyugeal  and  laryugeal  affections,  ozone  inhalations  have  been  warmly 
commended  (Fig.  52).  Many  ingenious  electrodes  for  nasal  and  pharyu- 
p-ul  work  have  been  devised,  two  very  useful  ones  being  shown  in  Figs. 
53  and  54. 


FIG.  53.— Curved  sponge  electrode  for  application  to  throat. 


FIG.  54.— Electrode  for  hydro-electric  applications,  post-nasal  and  pharyngeal. 
OZ.ENA. 

In  this  affection  some  electro-therapeutists  apply  cupric  electrolysis. 
In  1895  at  a  meeting  of  the  Belgian  laryngologists  and  otologists,  Cheval 

'Transactions  of  the  American  Laryngological  Association,  1887,  p.  14»i. 
*  Journal  de  Medecine,  Paris,  November,  1902. 
9  129 


130  ELECTRO-THERAPEUTICS. 

announced  the  cure  of  91  per  cent,  of  cases  of  ozrena  at  a  single  seance. 
He  employs  a  copper  needle  (positive  pole)  and  inserts  it  into  the  mucous 
membrane  of  the  middle  turbinated  bone,  and  introduces  a  steel  needle 
into  the  mucous  membrane  of  the  inferior  turbinated  bone  of  the  same 
side.  The  strength  of  current  is  between  18  and  20  milliamperes.  for  a 
period  of  10  minutes. 

ANAESTHESIA  OF  THE  PHARYNX. 

Induced  or  continuous  currents,  percutaneous  or  pharyngeal,  may  be 
used  in  such  cases.  Short  static  sparks  are  often  beneficial. 

LARYNGEAL  FATIGUE  (fatigue  vocale). 

Bordier  '  states  that  Moutier  and  Granier  of  the  Opera  in  Paris, 
had  been  able  to  prove  that  electro-static  applications  exerted  a 
favorable  influence  upon  laryngeal  fatigue.  The  patient  was  charged 
negatively  and  the  anode  or  grounded  point  electrode  was  applied 
near  the  mouth  and  nose.  Applications  daily  for  15  or  20  minutes 
showed  an  increased  duration  of  the  respiratory  movements,  the  pitch  of 
the  laryngeal  sound  was  raised,  and  the  quality  of  the  voice  became 
more  agreeable. 

ATROPHIC  PHARYNGITIS. 

Shurley !  used  cocaine  in  the  treatment  of  atrophic  pharyngitis  and 
then  applied  one  electrode  through  the  nose,  and  the  other  to  the  pos- 
terior and  lateral  wall  of  the  pharynx.  The  current  increased  both  the 
color  and  secretion  of  the  membrane.  With  the  use  of  the  faradic 
current,  Sajous  has  obtained  good  results. 

ANOSMIA. 

Anosmia  may  result  from  long  continued  rhinitis  or  from  a 
peripheral  lesion. 

The  treatment  maybe  external  and  internal.     The  external  treat 
ment  is  the  same  as  for  rhinitis,  save  that  the  current  is  stronger.     The 
internal  treatment  consists  in  the  direct  application  of  a  metallic  elect  n»de 
to  the  nasal  mucous  membrane. 

Rockwell  mentions  a  case  of  anosmia8  of  six  years'  duration,  where 
the  patient  could  only  perceive  the  odor  of  kerosene  oil  and  freshly 
ground  coffee,  and  who  was  entirely  cured  liv  two  applications  of  the 
faradic  current. 

1 "  Medical  Electricity.''  by  H.  Lewis  Jones. 

'Transactions  of  the  American  Larynpological  Association,  1887,  p.  146. 

$  Medical  and  Surgical  Electricity,  by  A.  D.  Rockwell,  p.  482. 


APPLICATIONS  IN  THE  SPECIALTIES.  131 


ASTHMA. 


Tin-  galvanic  current  over  the  pneumogastric  and  sympathetic 
regions  has  been  frequently  used  in  asthma,  with  asserted  good  results. 
The  faradic  current  is  sometimes  effective.  In  some  instances  persistent 
faradization  of  the  chest  and  neck  has  been  followed  by  marked  relief. 

Courtade,  in  a  communication  made  to  the  Societe  Medico-Chirur- 
gicale.1  recommended  the  application  of  electricity  to  the  lateral  cervical 
region.  The  positive  pole  is  placed  on  the  neck,  so  as  to  produce  a  con- 
dition of  elect  rot  onus, — /.  <•.,  a  diminution  of  the  excitability  of  the  nerve. 
Thus  directed  the  current  acts  upon  the  pneumogastric  at  first  in  a  cen- 
trifugal manner,  so  as  to  excite  the  bronchial  and  laryngeal  muscles  j 
following  this  it  acts  centripetally  upon  the  phrenic  nerve,  and  upon 
the  great  sympathetic.  The  excitation  of  the  latter  is  able  to  modify 
the  vaso-motor  activity  of  the  vessels  of  the  medulla  oblongata  and  the 
respiratory  centres.  The  results  were  found  to  be  very  favorable  in 
essential  asthma. 

II.  Otology. 
AUDITORY-NERVE  DEAFNESS. 

This  is  best  treated  by  the  bifurcated  electrode  and  the  battery  cur- 
rent, using  the  cathode  to  the  ears.  Gradually  vary  the  current  by 
employing  a  rhythmic  interrupter,  or  by  turning  the  current  on  and  off 
with  the  current  collector.  Ten  milliamperes  is  the  maximum.  Seancea 
of  5  or  6  minutes  are  long  enough.  Apply  to  both  ears  simultaneously,. 
so  as  to  prevent  vertigo.  Use  electrodes  of  a  one-inch  surface.  Place  » 
small  pad  of  moist  absorbent  wool  between  the  electrode  and  the  skin, 
because,  the  electrode  being  small,  the  density  of  the  current  is  great. 
One  variety  of  the  double  ear  electrode  is  shown  in  Fig.  55. 


FIG.  55.— Double  sponge-tipped  ear  electrode  insulated  with  hard  rubber. 

CHRONIC  SUPPURATION  OF  THE  MIDDLE  EAR. 

Rockwell  states  that  in  experimenting  on  these  cases  he  used  the  gal- 
vanic current.  The  theory  on  which  the  experiments  were  based  was 
that  ulcerous  conditions  in  the  ear  might  be  treated  electrically,  similarly 
to  the  same  conditions  elsewhere.  An  electrode  with  a  long,  narrow 
extremity,  covcm!  with  a  little  cotton,  was  inserted  into  the  auditory 

1  Le  Bulletin  Medicale,  February  21,  1906. 


1  U'2  ELECTRO-TH  KRAI'  1  ]  UTICS. 

canal  through  a  rubber  speculum,  the  canal  being  filled  with  tepid 
water.  The  electrode  is  usually  connected  with  the  negative  pole  of  the 
galvanic  current,  though  sometimes  with  the  positive.  The  circuit  is 
completed  by  the  hand  of  the  patient  holding  a  sponge  electrode,  or  rest- 
ing on  a  stationary  electrode.  Weak  currents  and  short  applications  are 
to  be  employed,  while  some  form  of  rheostat  is  indispensable. 

TINNITUS  AURIUM. 

Subjective  noises  can  sometimes  be  dispelled  at  once  by  battery 
currents. 

In  chronic  ear  disease,  when  patients  are  electrically  treated,  the 
tinnitus  is  often  found  associated  with  great  increase  in  the  irritability  of 
the  auditory  nerve. 

In  treating  tinnitus  aurium  select  two  small,  well-padded  electrodes, 
of  about  2  cm.  in  diameter,  to  form  a  divided  anode  ;  apply  one  to  each 
ear,  just  in  front  of  the  tragus.  The  cathode  (an  electrode  of  large  size) 
is  applied  to  the  nape  of  the  neck.  The  current  is  slowly  raised  to  5 
milliamperes.  Duration  10  minutes.  The  anode  usually  diminishes  the 
tinnitus,  the  cathode  iurceases  it ;  sometimes  the  reverse  occurs.  If  no 
improvement  follow  either  application,  it  is  futile  to  continue. 

Dr.  William  S.  Bryant l  details  excellent  results  obtained  from  elec- 
trical treatment- in  tubal  tinnitus  wherein  other  methods  had  failed.  The 
negative  pole  can  be  applied  to  the  tube,  preferably  through  the  nose. 
It  is  best  made  in  the  form  of  an  eustachiau  catheter,  conical  at  the  tip, 
and  iu  three  sizes.  It  should  be  insulated  to  within  three-quarters  of  an 
inch  of  the  end  of  the  electrode.  Duell's  electric  bougie  is  very  satis 
factory  in  the  most  refractory  cases.  Atrophy  calls  for  stimulation  and 
electricity. 

As  a  complete  rfaumS  of  the  uses  of  electricity  in  aural  diseases  and 
affections,  I  can  do  no  better  than  append  the  following  abstract  from  the 
excellent  paper  of  Dr.  J.  J.  Richardson,  of  Washington,  D.  C.,  entitled 
"Electricity  in  Otology." 

u  *  *  *  *  j  am  noj.  an  enthusiast,  who  claims  electricity  to  be  a 
panacea  for  all  diseases,  but  after  careful  experimentation  audobscr\a 
tion,  lam  convinced  that  it  at  least  possesses  great  possibilities  along  eer- 
tain  lines.  *  *  *  *  I  know  from  practical  experience  that  we  can 
by  its  employment  iu  one  form  or  another  l  >  stimulate  weak  muscles, 
(2)  relieve  pain,  either  by  direct  action  of  the  current  or  by  the  cata- 
phoric application  of  anaesthetics,  (3)  stimulate  absorption  of  inflam- 
matory exudates,  (4)  overcome  stenosis  or  complete  strictures,  and  i  B  at 
times  revive  nervous  activity.  A  thorough  knowledge  of  the  physiology 

1  Laryngoscope,  July,  1904. 

2  New  York  Medical  Journal,  February  25.  1905. 


APPLICATIONS  IX  THi:  SPECIALTIES.  133 

and  pathology  of  tin-  parts  we  are  treating  and  also  of  electro-physiology 
and  electro-physics  is  demanded.  Tin-  apparatus  must  be  of  the  high- 
est standard  and  under  perfect  control,  as  otherwise  we  are  assum- 
ing a  risk  which  is  unjustifiable,  and  may  inflict  injury  instead  of 
affording  relief.  For  example,  in  the  application  of  galvanism,  the 
polarity  of  the  current  is  of  the  greatest  importance.  The  negative  pole 
will  often  do  good  whilst  the  application  of  the  positive  may  be  painful 
and  even  injurious.  *  *  *  *  Again,  a  mild  current  will  fre- 
quently relieve  or  cure  conditions  where  a  stronger  one  would  aggravate 
them. 

a  *  *  *  *  There  are  different  methods  of  applying  electricity  to 
the  ears.  The  one  which  I  employ  for  both  the  galvanic  and  faradic  cur- 
rents, when  both  ears  are  to  be  acted  upon,  is  a  bifurcated  intra-auricular 
electrode,  the  metallic  ends  of  which  I  cover  with  moist  absorbent  cotton. 
For  the  indifferent  pole,  an  ordinary  sponge  electrode  is  placed  in  the 
hand  or  over  the  nape  of  the  neck.  I  frequently  apply  it  to  the 
enstachian  tube  by  introducing  a  hard-rubber  catheter  in  the  ordinary 
way,  and  passing  through  it  a  metallic  bougie  electrode,  applying  the 
other  electrode  over  the  mastoid  region.  In  this  way  it  acts  directly  <»n 
the  muscles  of  the  tube,  which  at  times  lose  their  normal  tonicity,  and  it 
also  stimulates  the  circulation  of  the  parts.  For  this  purpose  I  usually 
employ  the  faradic  current,  which  produces  a  sort  of  tingling  sensation, 
but  no  vertigo  or  other  symptoms  of  cerebral  irritation. 

"The  active  pole  for  therapeutic  purposes  should  most  always  be 
the  positive,  unless  electric  torpor  exists,  as  it  is  the  sedative,  deconges- 
tive  one.  The  negative  pole,  which  we  employ  in  studying  the  auditory 
nerve  excitability,  acts  in  the  inverse  sense  ;  with  the  faradic  current  the 
polarity  is  unimportant. 

"In  the  distressing  symptom  of  tinnitus,  electricity  will  frequently  be 
beneficial  where  other  forms  of  treatment  have  been  of  no  avail.  It  is 
in  these  cases  where  the  ordinary  treatment  of  inflation,  eustachian  and 
middle  ear  medication  have  been  instituted,  and  where  the  naso-pharynx 
and  nasal  cavities  have  been  treated  with  negative  results,  that  electricity 
offers  some  encouragement.  A  fair  percentage  of  the  patients  will  be 
greatly  l)enented,  and  one  occasionally  cured.  When  the  tinnitus  is  of 
labyrinthine  origin,  or  due  to  chronic  inflammatory  changes  in  the  middle 
ear,  the  constant  current  is  the  one  mostly  employed.  One  to  three 
milliamperes  are  sufficient  and  should  be  allowed  to  pass  from  6  to  10 
minutes.  Where  there  is  ankylosis  of  the  ossicles,  the  interrupted 
current  has  been  more  satisfactory  in  cases,  although  less  frequently 
employed  than  the  constant  current.  The  good  effects  are  to  be  found  in 
its  mechanical  action  on  the  adhesions,  and  to  its  stimulating  action  on 
the  circulation,  and  also  upon  the  weakened  muscles  of  the  middle  ear. 


134  EL  !•:<  T  R(  >-T  1 1 1-:  i  i  A  i  •  i-:  UTICS. 

"True  strictures  of  the  enstachian  tube  are  rare,  and  are  lx?st  treated 
by  electrolysis.  The  galvanic  current  is  utilized  for  this  purpose.  A 
hard-rubber  or  silver  catheter,  properly  insulated  with  rubber  up  to  its 
point,  is  introduced,  and  a  small  gold  bougie  is  passed  through  the  cathe- 
ter and  up  to  the  point  of  constriction  in  the  tube  ;  the  bougie  is  the 
active  electrode.  It  is  to  be  attached  to  the  negative  pole  of  the  battery. 
the  current  turned  on  slowly,  and  3  to  0  milliamperes  are  to  be  allowed 
to  pass.  After  6  or  8  minutes,  by  a  gentle  pressure  on  the  bougie,  it  will 
be  felt  to  pass  the  softened  stricture.  The  operation  is  a  little  painful, 
and  for  a  few  days  following  there  will  be  an  increased  amount  of  deaf- 
ness and  ringing  and  fulness  iu  the  ear.  On  the  third  day  usually  a 
celluloid  bougie  is  to  be  passed  and  at  the  same  intervals  of  3  or  4  days 
for  2  or  3  weeks.  The  dispensing  electrode  is  held  in  the  hand  in  pref- 
erence to  the  mastoid  region,  or  over  the  neck,  where  there  will  be  less 
tendency  to  cerebral  irritation. 

" Complete  success,  by  electrical  treatment,  for  deafness  cither  of 
tympanic  or  labyrinthine  origin,  is  of  rare  occurrence.  I  do  not  recall 
any  cases  that  I  have  treated  where  the  hearing  was  greatly  improved, 
except  those  naturally  resulting  from  the  diminution  of  the  subjective 
noises.  Hysterical  deafness,  like  hysterical  aphonia,  is  best  treated  by 
the  faradic  current.  Pruritus  of  the  auricular  canal  is  often  benefited 
by  this  form  of  treatment.  In  neuralgic  otalgia  the  interrupted  current 
is  very  efficacious  when  applied  by  means  of  an  intra-auricular  electrode. 
The  incomplete  anaesthetic  effect  of  cocaine  may  be  aided  by  the  action 
of  the  constant  current.  This  cataphoric  process  is  utilized  in  producing 
anaesthesia  of  the  tympanic  membrane  and  external  canal  for  slight  oper- 
ative procedures.  The  auricular  canal  is  filled  with  a  10  per  cent,  solu- 
tion of  cocaine  and  a  mild  current  allowed  to  pass  for  5  to  10  minutes, 
when  amesthesia  ensues.  This  same  process  has  been  utilized  by  some 
with  various  drugs  as  a  means  of  curing  deafness,  but  I  have  had  no 
personal  experience  along  these  lines,  and  the  results  published  are  not 
encouraging.  The  positive  pole  should  be  in  contact  with  the  fluid,  and 
the  negative  pole  applied  over  the  neck." 

III.  Ophthalmology. 

PARALYSIS  OF  THK  MTSCLES  OF  THK  EVK. 

This  maybe  cerebral  or  peripheral  in  character.  For  this  paralysis, 
galvanic  currents  are  preferable.  When  the  condition  is  thought  to  be 
cerebral  in  origin,  galvanization  of  the  sympathetic  should  be  resorted 
to.  Treatments  of  a  half-minute  duration  are  to  IK?  employed. 

Bi.i.ni  AROSPASM. 

Galvanization  or  faradi/at  ion  is  here  indicated,  for  t  hesame  reason  that 
it  is  indicated  in  torticollis.  Ptosis  is  to  be  treated  in  a  similar  manner. 


APPLICATIONS  IX  THE  SPECIALTIES.  135 


CATARACT. 


The  Russian  observer  Crussel '  claimed  t<>  have  obtained  perfect  suc- 
cess in  cases  of  cataract  by  the  galvanic  current.  His  method  was  to 
introduce  a  needle  into  the  lens,  which  was  connected  with  the  negative 
pole,  while  the  positive  was  applied  to  the  tongue:  in  this  way,  the  cata- 
ract was  subjected  to  mechanical  disintegration  by  the  needle,  to  the 
chemical  influence  of  the  negative  pole,  and  probably  also  to  the  macer- 
ating action  of  the  aqueous  humor  penetrating  the  lens,  through  the 
puncture  made  in  the  capsule  by  the  needle. 

ELECTROLYSIS  ix  DISEASES  OF  THE  LACRYMAL  CANAL. 

Lotine 3  reports  a  number  of  cases  of  disease  of  the  lacrymal  pas- 
sages in  which  he  successfully  employed  electrolysis  applied  by  electro- 
lytic  probes,  which  were  insulated  along  the  greater  part  of  their  length 
by  a  coating  of  the  same  material  as  that  used  to  cover  elastic  bougies. 
The  particular  portion  of  the  probes  so  insulated  could  thus  remain  in 
the  canaliculus  and  the  lacrymal  sac,  while  the  non-insulated  part  could 
occupy  the  lacrymal  duct.  The  techuic  was  as  follows  :  After  dilating 
the  canals  and  finding  the  stricture,  the  insulated  probe,  connected  with 
the  negative  pole,  is  introduced  into  the  strictured  portion  of  the  lacry- 
mal duct.  Then  the  positive  pole,  wrapped  in  cotton,  moistened  in  salt 
solution,  is  held  in  the  patient's  hand  or  introduced  into  the  correspond- 
ing cavity  of  the  nose.  The  resistance  is  gradually  decreased  for  half  a 
minute  until  the  current  measures  from  four  to  five  mi lliam pares.  The 
prol>e  is  then  moved  along  the  strictured  portion,  and  the  electrolysis  is 
continued  for  about  five  minutes  as  a  rule.  The  size  of  the  probe  used 
at  first  should  correspond  to  that  of  the  ordinary  sound  which  just  passes 
the  stricture.  Later  the  size  of  the  electric  probe  may  be  increased. 

RETINAL  AN.-KSTHESIA  AND  ITS  TREATMENT  BY  VOLTAIC  ALTERNATIVES. 

Dr.  L.  Webster  Fox  *  defines  retinal  anaesthesia  as  a  functional  disorder 
characterized  by  reduction  in  acuity  of  vision  and  marked  contraction 
of  the  visual  fields  (30°  to  55°  in  both  vertical  and  horizontal  meridians), 
unaccompanied  by  reversal  in  the  color  fields.  *  *  *  *  The  treat 
meut  recommended  is  the  daily  application  of  a  weak  current  of  1  or  2 
milliamperes,  the  session  being  often  minutes'  duration.  The  indifferent 
electrode  is  applied  to  the  temple  or  nape  of  the  neck  :  the  active  elec- 
trode is  applied  over  the  eye  or  eyes.  A  convenient  form  of  electrode  for 
this  purpose  is  shown  in  Fig.  56.  Improvement  follows  within  a  few 

'Evetzky  "  OH  the  Nature  of  Cataract,"  New  York  Medical  Journal,  July,  1880. 

'Roussky  Vratch.  May,  1904. 

'Journal  of  the  American  Medical  Association,  January  7,  1905. 


13G  ELECTRO-THERAPEUTICS. 

days,  and  recovery  is  rapid.  Errors  of  refraction  should  be  noted,  but  not 
corrected  until  the  cessation  of  electrical  treatment.  Voltaic  alternatives 
are  defined  as  a  series  of  sudden  reversals  in  the  polarity  of  the  electrodes 
of  a  voltaic  battery,  so  as  to  produce  an  interrupted  alternating  current. 
The  reversals  used  were  at  intervals  of  two  seconds.  Twenty-eight  cases 


FIG.  56.— Adjustable  eye  electrode,  for  one  or  both  eyes.    Adjustable  to  any  pupillary  distance. 

were  treated  with  invariable  benefit,  the  only  return  case  being  one  of 
progressing  myopia,  which  was  fitted  with  glasses  before  completion  of 
electrical  course.  The  author  asserts  "eminent  success  in  numerous  other 
lesions  of  the  eye,  vitreous  opacities,  retinitis  pigmentosa,  chorio-retinitis, 
and  choroiditis,  treated  by  this  method." 

MISCELLANEOUS  OPHTHALMIC  AFFECTIONS. 

Dr.  W.  Franklin  Coleman1  details  an  extensive  experience  with  the 
use  of  electricity  in  ophthalmic  practice,  with  the  galvanic  and  sinusoidal 
currents. 

The  cases  seletted  were  very  chronic  and  regarded  as  incurable  ;  and 
in  order  that  the  results  obtained  could  be  ascribed  to  the  current,  t he- 
diagnosis  had  been  confirmed  by  confreres  and  all  other  forms  of  treat 
ment  avoided. 

Prior  to  1890,  he  employed  the  galvanic  current  of  zinc-carbon  ele- 
ments, excited  by  a  solution  of  potassium  bichromate  ;  since  that  time, 
however,  he  has  used  the  Edison  street  current,  controlled  and  measured 
by  the  rheostat  and  meter  of  the  ordinary  wall  plate. 

The  alternating  or  sinusoidal  current  was  taken  from  a  transformer, 
he  using  30  to  35  measured  volts,  and  a  quantity  measured  at  5  milliam- 
peres.  With  a  force  of  30  volts  taken  from  the  direct  current,  and  t  he- 
electrodes  placed  on  the  lids  and  nape  <>f  the  neck,  the  meter  registered  5 
milliamperes,  hence  the  same  voltage  from  the  alternating  current  and 
the  same  resistance. 

He  prefers  galvanism,  in  consecutive  optic  atrophy,  because  of  the 
existing  exudates :  while  in  primary  atrophy,  the  alternate  current  would 

1  Transactions  of  the  Section  on  Ophthalmology  of  the  American  Medical  Asso- 
ciation, Boston,  June  5-8,  1906. 


APPLICATIONS  IX  THE  SPECIALTIES.  137 

appear  more  stimulating  to  the  nerves.  This  can  be  shown  by  comparing 
a  thirty- volt  current  from  the  dynamo  with  a  thirty- volt  galvanic  cur- 
rent; the  former  is  not  unpleasant  and  causes  a  brilliant  mosaic  of  dark 
and  light,  while  the  latter  causes  no  phosphenes,  unless  the  current  is 
interrupted  and  the  burning  is  so  intense  that  it  cannot  be  endured  for 
more  than  half  a  minute. 

He  summarizes  his  cases  as  follows  : 

Optic  Atrophy. — Fourteen  patients,  23  eyes.  In  5  eyes  in  which 
vision  =  light,  40  per  cent,  were  improved, — one  to  seeing  hand  move- 
ments and  one  to  20/67. 

In  18  eyes  in  which  vision  =  form,  64  per  cent,  were  improved. 
Four,  60  to  125  per  cent. ;  two,  300  per  cent. ;  three,  500  per  cent. ;  one, 
1500  per  cent. ;  two  from  seeing  fingers  to  reading.  In  six  there  was  no 
improvement. 

Vitreous   Opacities. — Seven  patients,  12  eyes.      In  5  eyes  vision  = 
light,  one  improved  to  counting  fingers  at  6  inches ;  one  was  unimproved. 
In  12  vision  =  form  ;  90  per  cent,  were  improved  ;  seven,  40  improved  ; 
four,  20  to  100  per  cent. ;  six,  200  to  700  per  cent. 

.1  mhlyopia. — Seven  patients,  10  eyes,  all  were  improved.  Four,  20  to 
100  per  cent. ;  six,  200  to  700  per  cent. 

Sequels  of  Iritis. — Two  patients,  4  eyes.  All  were  improved;  one 
from  light  perception  to  20/70  ;  one,  100  per  cent,  ;  two,  200  per  cent. 

Intra- Ocular  Hemorrhage. — One  eye,  vision  improved  from  light  to 
20/20. 

Retimtis Pigmentosa. — One  patient.  One  eye  improved  100  per  cent.; 
one  eye  was  not  improved. 

Itetinal  Thrombosis. — One  eye,  vision  was  improved  from  fingers  at 
14'  to  6.15  and  0.5  at  12  inches. 

Sequela?  Central  Pet  i  nit  is. — One  patient,  two  eyes,  no  improvement. 

Asthenopia. — Three  eyes.     Recovered. 

Xanthelasma. — Two  patients.     Recovered. 

Paresis  of  Ocular  Muscles. — Two  patients.  One  recovered  and  one 
was  much  improved. 

Alopecia  of  Lids. — One  patient.     Improved. 

XiHitatitm. — One  patient.     Recovered. 

Pterygium. — One  eye.     Xo  improvement. 

Thus,  contrary  to  the  contention  of  the  erudite  and  lamented  Noyes, 
and  ••  most  oculists''  (Burnett),  electricity  does  seem  to  justify  its  claim 
to  usefulness  in  ophthalmic  practice. 


CHAPTER  X 
HIGH-FREQUENCY  CURRENTS. 

A  COMPREHENSIVE  study  of  high- frequency  currents,  the  phenomena 
connected  with  them,  and  their  remarkable  modes  of  application,  has  not 
as  yet  been  thoroughly  mastered.  Literature  upon  the  subject  is  rapidly 
increasing,  but  it  is  a  perplexing  matter,  in  the  present  state  of  our 
knowledge,  to  discriminate  between  the  good  and  the  faulty.  In  present 
ing  the  appended  chapter  on  high-frequency  currents,  no  attempt  at 
originality  has  been  made  ;  on  the  contrary,  difficulty  was  encountered  in 
selecting  authoritative  statements  bearing  on  the  subject.1 

I.   Historical  Introduction. 

The  employment  of  high-frequency  currents  for  the  cure  of  disease 
was  introduced  to  the  profession  by  D' Arson val.  In  1842  Professor 
Joseph  Henry  asserted  that  the  discharge  from  a  Leyden  jar  was  oscillatory 
in  nature.  Later  Lord  Kelvin,  Helmholtz.  and  others  confirmed  the  view 
advanced  by  Henry. 

In  1881  \V.  J.  Morton,  of  New  York,  published  in  the  Medical  Record 
an  article  entitled  "A  Xew  Induction  Current  in  Medical  Electricity." 

In  1886  and  1887  Hertz  and  Lodge  gave  to  the  world  a  study,  new  in 
conception  and  reasoning,  that  dealt  with  experimentation  on  electric 
waves. 

In  1870  Ward  asserted  that  sparks  generated  by  an  induction  coil 
operated  by  a  very  rapid  rotary  interrupter  were  capable  of  giving  8000 
interruptions  per  second. 

In  1890  D'  Arson  val  showed  that  beyond  5000  excitations  per  second, 
the  muscular  contractions  diminish  in  proportion  to  the  increase  in  the 
number  of  alternations.  To  support  this  assertion,  he  had  made  an  alter- 
nater  capable  of  giving  10,000  alternations  per  second,  and  in  April,  1  S!»  l . 
he  indisputably  demonstrated  that  a  current  of  high  frequency  and 
potential  could  be  made  to  traverse  the  human  body  ;  increasing  the  oxi- 
dation consequent  upon  respiration,  diminishing  the  excitability  of  the 
tissues,  and  lowering  arterial  tension. 

In  1893  Oudin  devised  the  "  resonator  ;"  but  it  was  Tesla  who,  in 
1891,  aroused  greatest  enthusiasm  by  the  employment  of  altei  naters  with 

1  Although  of  late  I  have  largely  employed  currents  of  high  frequency,  I  have  not 
hesitated  to  avail  myself  of  the  excellent  work  on  "  High-Frequency  Currents  in  the 
Treatment  of  Some  Diseases,"  by  Chisholm  Williams,  published  by  the  Rebnian  Com- 
pany, New  York. 
138 


HIGH-FREQUENCY  CURRENTS.  139 

a  multiplicity  of  poles,  and,  by  the  introduction  of  transformers,  he  was 
enabled  to  increase  the  potential  to  an  almost  incredible  number  of  volts, 
making  possible  the  assertion  and  proof  that  high-frequency  and  high- 
potential  currents  could  be  made  to  pass  through  the  human  body,  with 
sufficient  energy  to  light  up  several  incandescent  lamps,  without  the 
slightest  danger  to  the  person  through  whom  the  currents  were  passing. 

II.   Principles  and  Apparatus. 

The  nature  of  a  discharge  is  dependent  upon  the  character  of  the 
electro -motive  force  producing  it,  and  likewise  upon  the  manner  of  dis- 
charging it.  Thus,  when  a  ball  prime  conductor  of  a  static  machine  is 
made  to  discharge,  the  discharge  occurs  in  a  disruptive  manner,  consist- 
ing of  a  series  of  discharges  between  the  ball  and  the  object  at  which 
it  discharges.  When  a  condenser,  as  a  prime  ball  conductor,  charged 


FIG.  57.— Oscillatory  nature  of  the  Leyden  jar  discharge. 

with  a  very  high  potential,  is  discharged  into  a  conductor  having  a  cer- 
tain self  induction  and  a  slight  resistance,  there  result  extremely  rapid 
isochronous  oscillations,  constituting  the  so-called  high-frequency  cur- 
rents. Hertz  showed  the  frequency  of  these  oscillations  to  be  hun- 
dreds of  millions  per  second.  The  alternations  of  a  Ruhrnkorff  coil 
are  about  200  per  second,  with  an  electro-motive  force  of  from  ten  to 
two  hundred  thousand  volts,  while  the  alternations  of  the  high-frequency 
currents  are  from  100,000  to  1,000,000  volts,  depending  upon  the  means 
employed. 

The  current  is  obtained  from  the  main,  bichromate  batteries  or  from 
an  accumulator.  A  Ruhmkorff  coil  is  required  to  transform  the  current 
to  one  of  high  tension.  The  interrupter  employed  may  be  the  motor- 
mercury  interrupter,  or  the  Wehnelt  or  turbine  break.  The  alternating 
current  generated  by  the  coil  must  be  transformed  by  the  condenser  into 
a  high-frequency  current.  The  condenser  consists  of  two  Franklin  plates, 
enclosed  in  a  flat  box,  whose  exterior  exhibits  the  small  solenoid  and  the 
spark-gap  with  connecting  screws.  Another  construction  is  where  two 
Leyden  jars  are  placed  behind  the  spark-gap,  and  under  a  bell  jar  to 


140 


ELECTRO-THERAPEUTICS. 


dampen  the  sound.  Two  conductors  arising  from  the  outer  tin-foils 
of  the  Leyden  jars  end  in  two  terminals,  between  which  a  third  is  inter- 
posed. As  is  well  known,  the  vibrations  from  a  Leyden  jar  are  oscilla- 
tory in  nature  (Fig.  57).  Where  general  D' Arson  valizatiou  is  required, 
the  large  and  small  solenoid  are  joined  to  this  terminal. 

The  following  are  the  principal  and  most  widely  used  varieties  of 
high-frequency  current  apparatus  : 

Morton's .... 
D'Arsonval's 
Tesla's  . . 


Oudin's.. 


high-frequency  apparatus. 

f  resonator  and 
I  its  varieties. 

MORTON'S  "STATIC  INDUCED  CURRENT"  HIGH-FREQUENCY  APPARATUS. 

The  modus  opemndi  of  Morton's1  apparatus  is  as  follows :  The  pat  in  it 
is  directly  in  circuit  with  the  outside  coatings  of  two  Leyden  jar  con- 
densers iu  series  (Fig.  58).  The  spark-gap  and  machine  are  in  multiple 


FIG.  68.— Morton's  "static-induced  current"  high-frequency  apparatus.1 

with  each  other.  With  the  patient  included  in  circuit  in  the  manner 
shown  in  the  diagram  we  do  not  know  the  value  of  the  inductance  and 
resistance  offered  by  him.  The  arrangement  of  two  condensers  of  small 
capacity  is  conducive  to  the  production  of  oscillatory  currents  of  rela- 
tively high  frequency,  and  such  currents  will  be  produced  if  the  patient 
offers  a  sufficiently  low  resistance  and  inductance.2 

'.Journal  of  Advanced  Therapeutics,  January,  1903. 

2  For  a  detailed  account  see  articles  by  Dr.  W.  J.  Morton  in  The  Medical  Uecnrd. 
pp.  ::ti")-371,  395-398, 438-440,  April  2, 9,  and  16,  1881 ;  and  pp.  97-104,  January  :M,  1MM. 


HIGH-FE I :Q  I  I : N  <  V  CUEREXTS. 


141 


D'ARSONTAL  HIGH-FREQUENCY  APPARATUS. 

In  the  D'Arsonval  apparatus1  (Fig.  59)  the  terminals  of  the  second- 
ary of  an  induction  coil  are  respectively  connected  with  one  terminal  of 
each  of  two  condensers.  A  spark-gap  is  placed  across  the  secondary 


li 


INDUCTION  COIL 


In 


FIG.  59.— D'Arsonval  high-frequency  apparatus. 

circuit.  The  other  two  terminals  of  the  condensers  are  connected  with 
the  ends  of  a  short  coil  of  a  few  turns  of  thick  copper  wire.  One  elec- 
trode is  connected  with  one  end  of  the  short  coil  and  the  other  electrode 
is  adapted  by  a  sliding  contact  to  include  in  circuit  with  the  patient  any 
desired  length  of  the  short  coil,  and  thus  regulate  the  effect  produced 
upon  him.  A  straight  rod,  or  tube,  of  copper  may  be  substituted  for  the 

'In  Comptes-rendus,  vol.  cxvi.,  1893,  pp.  630-633,  D'Arsonval  (quoted  in  the 
Second  Report  of  the  Committee  on  Current  Classification  and  Nomenclature,  and 
read  before  the  American  Electro-Therapeutic  Association,  September  24,  1903)  stated 
in  substance  (a)  that  he  had  communicated  to  the  Societe  de  Biologie,  February  24  and 
25,  1891,  the  "astonishing  fact"  that  when  the  frequency  of  a  current  was  very  great 
excitation  of  the  nerves  and  muscles  was  not  produced  ;  (b)  that  the  sparking  distance 
— and  therefore  potential  difference — between  conductors  connected  with  the  ends  of 
the  short,  thick  wire  coil  was  greater  than  at  the  spark-gap  across  the  secondary  ter- 
minals of  the  induction  coil  ;  (c)  that  a  very  strong  oscillating,  high-frequency  current 
was  produced,  sufficient  to  raise  a  one-ampere  incandescent  lamp  to  a  white  heat  when 
in  series  with  two  persons  completing  the  branch  circuit  between  the  terminal  of  the 
thick  wire  coil ;  (d)  and  that  he  had  been  able  to  generate  in  a  branch  circuit,  includ- 
ing his  own  body,  a  current  of  more  than  three  amperes  without  any  other  effect  than  a 
sensation  of  heat  in  the  hands. 


142 


ELECTRO-THER  APEUT I  (  S. 


short  coil  to  increase  the  frequency  of  the  current,  by  diminishing  the 
inductance.  A  static  generator  may  be  substituted  for  the  induction  coil. 
Currents  of  exceedingly  high  frequency  are  produced  by  the  D' Arsonval 
apparatus.  When  currents  of  much  higher  potential  are  desired  they  can 
be  obtained  from  a  fine  wire  coil  of  relatively  many  turns,  inclosed  in  a 
glass  tube  filled  with  petroleum,  and  inserted  in  the  thick  wire  coil. 

That  the  frequency  must  be  exceedingly  high  is  proved  by  an  experi- 
ment made  by  Dr.  Sheldon.  In  place  of  the  induction  coil  for  producing 
the  spark  at  the  gap,  he  employed  a  Holtz  machine. 

TESLA'S  HIGH-FREQUENCY  APPARATUS. 

This  is  described  by  its  author  as  follows  :  ' '  The  writer's  experiences 
tend  to  show  that  the  higher  the  frequency  the  greater  the  amount  of 


I 


Fio.  60.— The  Tesla  transformer. 

electrical  energy  which  may  be  passed  through  the  body  without  serious 
discomfort  •  *  *  *  *  By  taking  the  globe  of  a  lamp  in  the  hand, 
and  by  bringing  the  metallic  terminals  near  to  or  in  contact  with  a  con- 
ductor connected  to  the  coil  [that  is  to  say,  connected  to  one  terminal  of 
the  secondary  of  an  induction  coil  whose  primary  is  energized  by  an 
alternating  current  of  very  high  frequency],  the  carbon  is  brought  to 


FIG.  61.— Diagram  of  the  Oudin  resonator.  The  Tesla  coil  is  omitted.  The  current  from  the 
induction  coil  is  connected  with  the  inner  tin-foil  of  the  Leyden  jars.  The  outer  coat  of  one  Leyden 
jar  is  in  connection  with  the  resonator,  and  is  also  grounded.  The  outer  coat  of  the  other  Leyden  jar 
is  connected  to  the  handle,  H,  which,  by  a  sliding  movement  either  in  the  vertical  or  the  horizontal 
direction,  decreases  or  increases  the  amount  of  winding  of  the  resonator,  if  is  the  spark-gap  for  regu- 
lating the  amount  of  current. 

FIG.  62.— The  Oudin  resonator  and  Tesla  coil,  with  electrode.    (Biddle.) 


FIG.  63. — Glass  electrodes.  This  set  of  electrodes  has  been  especially  designed  for  convenience  in 
changing  from  one  electrode  to  another.  The  hard-rubber  handle  is  made  very  long  and  provided 
with  a  universal  socket  in  which  any  of  the  electrodes  may  be  fastened  or  loosened  by  merely  moving 
the  ring  upon  the  sleeve  which  holds  the  stem  of  the  electrodes. 


IIMrH-FREQUK.M  V   <  TIMJENTS.  U:J 

bright  incandescence  and  the  glass  is  rapidly  heated.  With  a  100-volt 
10  c.  p.  lamp,  one  may  without  great  discomfort  stand  as  much  current 
as  will  bring  the  lamp  to  a  considerable  brilliancy  ;  but  it  can  be  held  in 
the  hand  only  for  a  few  minutes,  as  the  glass  is  heated  in  an  incredibly 
short  time.''1 

In  Tesla's  apparatus  (Fig.  60)  the  inner  tin-foils  of  the  Leyden  jars 
are  positively  and  negatively  charged  from  the  secondary  terminals  of  the 
Iiiihmkorff  coil.  The  outer  foils  are  in  connection  through  the  primary 
winding  of  Tesla's  transformer,  as  is  shown  in  the  illustration,  and  through 
the  spark-gap.  These  high-frequency  alternating  currents  induce  alter- 
nating currents  in  the  secondary  coil,  combining  high  frequency  with 
high  tension. 

Tin:  Ounix  RESONATOR.     (Figs.  61,  62.) 

Although  Hertz  had  previously  employed  the  phenomenon  of  reso- 
nance in  his  experiments,  it  is  to  Dr.  Oudin  that  the  resonator  owes 
its  introduction  into  electro-therapeutics.  The  apparatus  consists  of  a 
laruv  solenoid  of  uninsulated  copper  wire  of  medium  thickness,  wound 
spirally  about  a  vertical  cylinder  of  well  paraffined  wood.  The  length 
of  the  wire  employed  varies  from  45  to  60  meters,  and  its  diameter  from 
2.5  to  3  millimeters. 

It  makes  50  or  more  turns  about  a  wooden  cylinder,  40  to  50  cm.  in 
height  and  30  cm.  in  diameter;  while  the  distance  between  the  spirals  is 
about  8  millimeters. 

GLASS  VACUUM  ELECTRODES.     (Figs.  63,  64. ) 

These  consists  of  glass  tubes  of  various  shapes  and  sizes,  which  offer 
a  barrier  for  retarding  the  entrance  of  high-frequency  currents  to  the 
part  being  treated.  Tesla's  electrodes  have  as  a  resisting  medium  the 
rarefied  air  contained  within  them.  Those  of  Dean  are  made  up  of  a 
series  of  pieces  of  thick,  hollow  glass,  in  which  there  is  a  very  high 
vacuum.  The  glass  is  sufficiently  thick  to  prevent  sparking,  thus  pre- 
serving the  integrity  of  the  vacuum.  If  the  finger  be  approached  to  one 
of  these  glass  electrodes  when  connected  to  the  apparatus,  a  violet  brush 
discharge  will  be  observed  between  the  glass  and  the  finger.  This  dis- 
charge is  produced  at  the  outer  side  of  the  tube  by  induction.  The  bet- 
ter the  contact  between  the  glass  and  the  skin,  the  less  will  be  the  amount 
of  brush  discharge  and  of  heat  produced.  The  glass  tube  electrode  with 

'Transactions,  American  Institute  Electrical  Engineers,  vol.  viii.  pp.  267-319, 
New  York.  May  I'O,  1891  ;  and  Journal,  Institution,  Electrical  Engineers,  vol.  xxi. 
pp.  51-163,  London,  February  3,1892  ;  article  on  Phenomena  of  Alternating  Currents 
of  Very  High  Frequency,  published  in  the  Electrical  World,  vol.  xvii.  pp.  128-130, 
Xc\\  V.u-k,  February  21,  1891. 


144 


ELECTKO-THEKAPEUTK'S. 


partial  vacuum   becomes    luminous   from    the  discharge  of  the  Current 
through  this  vacuum,  which  acts  as  a  conductor:  the  luminosity  of  the 


WAITE  &  BABTLETT  M'F-C  Co. 


FIG.  64.— Piffard's  glass  electrode. 


gas  is  due  to  its  incandescence  and  tends  to  heat  the  glass  wall  of  the  tube, 
and  these  tubes  occasionally  crack  from  this  cause. 

CATAPHORESIS  ELECTRODE. 

The  cataphoresis  electrode  made  by  K.  Schall  is  most  useful  for 
applications  to  large  areas,  such  as  the  abdomen,  chest,  and  back.  It  has 
a  diameter  of  8  inches,  and  consists  of  an  aluminium  disk  over  which  is 
stretched  a  sheet  of  parchment. 

Dr.  William  J.  Morton,  of  New  York,  long  ago  found  a  deficiency 
in  vacuum  tubes  for  phoric  action,  for  high-frequency  currents.  He 
remarks :  "A  deficiency  of  all  such  electrodes  is  that  the  bulk  of  the 
current  passes  at  the  periphery  of  the  flat  disk.  To  obviate  this  I  have 
•elongated  the  entering  metallic  conductor  to  the  region  of  the  flat  sur- 
face and  have  made  it  a  sharp  point. 

"  Again,  if  desired,  I  attach  a  thin  metallic  plate  of  tin-foil  or  other 
metal  upon  the  outer  side  of  the  glass  upon  its  flat  side.  The  diameter 


Tin  fa"  c.nO«n»r  pUt. 


Fio.  65.—  Morton's  cataphoric  electrode.    (Waite  &  Bartlett  Manufacturing  Co.) 

of  this  plate  is  considerably  less  than  the  diameter  of  the  circular  and 
flat  surface  of  the  electrode  (Fig.  65). 

u  As  now  arranged  the  current's  action  is  concentrated  to  this  Hat 
surface  of  the  electrode  and  the  cataphoric  action  is  correspondingly 


HIGH-FREQUENCY  CTKKENTS.  145 

enhanced.  But  the  tiu-foil  adds  to  the  pain  ul'  tlie  application,  and  I 
prefer  to  use  the  sharp-pointed  electrode  without  the  tin-foil  condenser." 

Other  varieties  of  electrodes  are  the  condenser  (vide  Fig.  61,  CE, 
supra)  and  the  brush  or  effluve. 

An  effluver  or  electrode  for  applying  high-frequency  currents  con- 
sists of  a  piece  of  metal,  generally  cylindrical  in  form,  having  on  its 
upper  surface  a  series  of  fine  points,  from  which  the  discharge  jumps  to 
the  patient.  The  character  of  the  effluve  may  be  modified  by  the  type 
of  effluver  used:  the  greater  the  number  of  points,  the  more  thinned  will 
be  the  effluve  (vide  Fig.  07,  infra). 

III.   Physical  Properties. 

A.  INDUCTION  EFFECTS. 

B.  ELECTRO-STATIC  EFFECTS. 

C.  DYNAMIC  EFFECTS. 

D.  RESONANCE  EFFECTS. 

A.  INDUCTION  EFFECTS. 

Induction  effects  are  most  intense  in  their  action,  as  the  apparatus 
giving  rise  to  them  is  of  a  potent  nature.  Induction  is  the  effect  of  an 
electro-magnetic  flux  on  a  neighboring  body  susceptible  of  an  induced 
magnetic  saturation,  the  intensity  of  the  electro -motive  force  being  pro- 
portional to  that  of  the  rate  of  variation  of  the  magnetic  changes  or 
multiplied  by  the  frequency.  Therefore,  upon  the  human  body,  one 
may  bring  about  a  high  frequency  and  a  low  tension  equal  to  that  of  a 
high  tension,  and  low  frequency  on  the  same  or  equivalent  mass. 

B.  ELECTRO -STATIC  PROPERTIES. 

Most  high-frequency  apparatus  is  so  constructed  as  to  permit  of  the 
production  of  physical  phenomena  analogous  to  the  modern  static 
machine.  For,  if  we  connect  the  two  ends  of  the  short  solenoid  to  two 
plates  of  insulated  metal  which  are  separated  from  each  other,  a  power- 
ful electro-static  field  will  be  created  ;  which  can  be  demonstrated  by 
bringing  a  Geissler  tube  between  them,  when  a  glow  will  be  manifested, 
as  though  attached  to  the  terminals  of  an  induction  coil.  If  a  similar 
plate  of  glass,  covered  on  either  side  with  tin-foil,  be  interposed,  and 
each  side  have  attached  to  it  a  wire  to  which  an  electric  lamp  is  fixed, 
it  will  be  seen  that  the  filament  will  glow  ;  proving  the  presence  of 
electrical  waves  proceeding  from  an  electro-static  field. 

C.  DYNAMIC  PROPERTIES. 

This  is  proved  by  the  ease  with  which  these  currents  circulate  in  an 
open  circuit.  Imagine  a  conductor  connected  to  a  high-frequency  appa- 
ratus by  the  two  poles,  and  in  the  middle  of  this  conductor  a  piece  of  fine 

10 


140  ELECTRO-THERAPEUTICS. 

wire  of  high  resistance  be  interposed  ;  circulate  the  currents  and  the  wire 
will  glow  and  perhaps  fuse.  If  sealing-wax  is  employed  to  couple  the 
wires,  the  current  will  jump  from  each  wire,  producing  sufficient  heat  to 
fuse  the  wax. 

D.  RESONANCE. 

A  resonator  is  an  accessory  to  the  apparatus,  whose  purpose  is  to 
augment  the  tension  of  the  current  and  to  create  in  the  vicinity  a  more 
powerful  electro-static  field.  When  two  bodies  vibrate  in  unison  they  are 
said  to  be  syntonous.  The  Hertz  resonator  is  one  of  low  resistance  and 
capable  of  giving  very  rapid  oscillations,  it  is  likewise  of  small  capacity 
and  self-induction.  It  consists  of  an  induced  current  formed  by  a  length 
of  copper  wire  so  bent  as  to  form  nearly  a  circle,  but  having  two  balls  at 
the  extremities  where  they  are  brought  near  one  another. 

This  resonator  is  brought  into  the  field  of  another  vibrator  and  tuned 
in  syntony  with  the  latter;  as  soon  as  the  resonator  is  put  in  action, 
Hertz's  resonator  will  emit  sparks  from  the  two  balls.  All  the  other 
resonators  are  founded  on  the  above  principle. 

IV.  Methods  of  Application. 

There  are  four  chief  methods  of  applying  high  frequency  currents, 
as  distinguished  by  D'  Arsonval : 

1.  Direct  application  or  by  derivation. 

2.  Indirect  application  or  auto- conduction  by  the  solenoid. 

3.  An  to- condensation  (Apostoli). 

4.  By  local  application. 

1.  DIRECT  APPLICATION. 

Connect  the  patient  by  two  large  handles  to  the  ends  of  the  small 
solenoid.  The  currents  will  pass  through  him  by  derivation  ;  for  by 
virtue  of  the  phenomenon  of  self-induction,  the  solenoid  offers  a  uivat 
resistance,  which  can  be  proved  by  interposing  an  incandescent  lamp  in 
the  circuit,  when  it  will  glow.  If  the  connection  between  the  patient's 
skin  and  the  handles  be  defective,  small  sparks  will  be  observed  to  pass. 
To  increase  the  area  of  penetration,  connect  some  part  or  member  of  the 
patient  to  one  end  of  the  small  solenoid,  and  the  other  end  to  a  metallic 
plate  in  the  water  of  the  bath,  near,  but  ndt  in  contact  with  the  skin. 
If  the  contact  be  imperfect,  small  ulcers  may  result.  With  powerful 
installations,  when  the  handles  are  used  after  prolonged  electrification, 
and  with  500  or  more  milliamperes,  heat  and  tingling  may  be  experienced 
in  the  hands  and  arms.  The  above  methods  are  termed  stabile  or 
bi-polar. 


HIGH-FREQUENCY  (TKKEXTS.  147 

Iii  the  labile  method,  a  fixed  electrode  connects  the  patient  to  the 
solenoid.  The  other  end  is  manipulated  by  the  physician,  who,  with  an 
insulated  handle,  is  enabled  to  apply  its  electrode  end  to  the  desired  part 
In  approaching  the  skin  with  the  insulated  electrode,  sparks  appear,  and 
the  momentary  contact  produces  an  erytheinatous  flush. 

The  stances  should  be  brief.  In  systemic  affections  begin  with  a 
lew  minutes'  direct  auto-condensation  or  auto-conduction  every  day. 
Note  any  subjective  symptoms.  If  the  dosage  has  been  in  excess,  the 
patient  experiences  a  feeling  of  fatigue.  The  D' Arson  val  milliampere- 
meter  should  be  employed,  the  range  of  which  should  extend  to  700 
milliamperes. 

In  the  local  treatment  we  observe  that  a  reaction  is  produced  at  the 
time  and  continues  for  some  hours  thereafter.  Thus,  in  a  patch  of  lupus 
vulgaris,  a  glass  electrode  of  low  resistance  connected  to  the  free  end  of  the 
resonator  and  placed  in  actual  contact  with  the  patient  would  be  used, 
and  by  a  judicious  choice  of  the  number  of  spirals  called  into  play,  the 
discharge  is  reduced  to  almost  nil.  After  an  application  lasting  five 
minutes,  the  part  feels  hot  and  looks  inflamed.  The  warmth  increases 
until  the  sixth  hour,  but  by  the  following  morning  has  entirely  dis- 
appeared. The  inflammation,  however,  has  persisted.  After  a  few 
seances  the  patch  dries  up  and  scales,  but  the  pigmentation  remains. 

The  treatment  may  be  applied  once  or  twice  daily  for  two  weeks, 
then  once  daily,  or  every  other  day,  for  the  same  period,  reducing  the 
imml)er  of  applications  week  by  week. 

An  acute  pain,  produced  by  disease,  will  be  augmented  at  the  com- 
mencement of  energetic  treatment.  Defective  contacts  between  the 
patient  and  the  apparatus,  or  in  the  apparatus  itself,  may  cause 
unpleasant  sensations  or  shocks. 

L'.   AUTO-CONDUCTION  BY  THE  SOLENOID. 

By  this  method  (Fig.  66)  the  patient  is  not  in  actual  contact  with  the 
solenoid;  his  body  becomes  saturated  in  the  field  of  the  current, — L  e., 
sparks  may  be  drawn  from  him.  If  a  lamp  of  20  volts  be  used  to  close 
the  circuit  of  a  single  coil  of  thick  wire,  it  illuminates  with  a  bright  light 
at  a  distance  of  more  than  three  feet. 

Place  the  patient  in  a  large  solenoid,  and  have  him  join  his  arms  so 
as  to  form  a  circuit,  which  is  completed  by  an  incandescent  lamp,  the 
terminals  of  which  communicate  with  the  hand.  The  lamp  is  lighted 
with  the  induced  current  in  the  circuit  thus  formed.  Any  conducting 
body  placed  in  this  field  becomes  influenced  with  induced  currents,  and 
if  a  single  copper  wire  of  one  turn  is  introduced,  the  induction  produced 
in  the  latter  will  be  sufficient,  to  light  up  two  lamps  of  110  volts  mounted 
in  series. 


148  ELECTRO-THKIJ  A  I M; I    I  I (  S. 

3.  AUTO-CONDENSATION. 

In  this  method  the  patient  is  attached  to  the  solenoid  in  the  usual 
way,  but  the  other  end  is  attached  to  a  large  metallic  plate,  brought  near 
the  patient,  but  insulated  from  contact  with  him.  Thus  the  metal 
plate  and  the  body  of  the  patient  form  the  armatures  or  coatings  of  a 
condenser  arrangement,  having  a  large  electrical  capacity,  which  is 
charged  and  discharged  as  the  potentials  at  tin-  extremities  of  the  sole- 
noid vary.  The  patient  lies  upon  the  insulating  cushions  of  the  couch, 
the  current  passing  to  him  either  by  a  handle  of  bare  metal  held  in  the 
hand,  or  by  an  electrode  applied  to  the  desired  part. 

4.  LOCAL  APPLICATIONS. 

These  are  especially  applicable  in  the  form  of  brush  discharges 
(Fig.  67).  Potentials  as  high  as  possible  are  required  for  these  discharges. 
This  may  be  accomplished  by  employing  a  secondary  coil,  which  is  oil 
immersed,  or  air  insulated.  In  1892  Oudin  devised  his  resonator,  made 
of  an  open  solenoid  of  wire,  which  could  be  connect  eel  as  an  extension  of 
one  end  of  the  solenoid  of  a  high-frequency  apparatus,  and  served,  when 
carefully  adjusted,  to  raise  the  potential  to  such  an  extent  that  a  long 
brush  discharge  could  be  obtained  from  its  free  extremity. 

V.  Physiological  Properties. 

Currents  of  high  frequency  and  high  potential  produce  no  action  on 
sensory  or  motor  nerves.  When  a  person  or  a  number  of  persons  are 
placed  in  the  external  circuit,  and  there  are  interposed  incandescent 
lamps  of  125  volts,  one  ampere,  the  filaments  will  light  up.  without  pro- 
ducing sensations  in  the  persons  in  the  circuit.  With  more  intense  cur- 
rents, only  a  slight  sensation  of  heat  will  be  perceived  at  the  point  of 
entrance  and  exit. 

H.  Lewis  Jones  controverts  the  assertion,  maintaining  that  if  the 
current  in  each  lamp  had  been  three  amperes,  it  would  certainly  have 
destroyed  life,  whether  the  direct  or  the  alternating  cm-rent  had  been 
employed. 

It  has  been  argued  that  the  incandescence  occasioned  in  the  lamp 
is  caused  by  the  increased  resistance;  in  the  filament  of  the  lain]),  due  to 
the  very  high  frequencies,  and  that  a  smaller  cm-rent  at  a  proportionately 
high  voltage  will  make  it  glow. 

Another  theory  advanced  to  account  for  this  phenomenon,  is  that  the 
rushes  of  current  are  very  considerable  while  they  last,  but  their  dura- 
tion is  so  very  brief,  that  the  total  current  passing  in  a  given  time  is  rela- 
tively small.  Others  maintain  that  a  molecular  bombardment,  rather 
than  an  electric  current,  is  really  the  energy  dissipated.  D'Arsonval 


Auto  Conduction  Caee 


FIG.  66.— Treatment  by  auto-conduction.  S  S,  secondary  terminals  of  induction  coil ;  B  B, 
cords  to  the  auto-conduction  cage  from  the  Oudin  resonator:  /,  ,7,  Leyden  jar;  I). <  >/.,  spark-gap; 
when  sliding  in  the  direction  "  D,"  the  current  suffers  a  loss  in  intensity,  and  vice  versa. 


FIG.  67.— Treatment  by  the  effluvation  method.  The  condenser  electrode,  B,  is  in  connection 
with  the  top  of  the  resonator.  Patient  is  seated  upon  an  insulated  platform,  holding  the  electrode,  A, 
which  is  the  other  pole,  from  the  outer  side  of  the  Leyden  jar,  L  J.  ( By  grounding  the  outer  side  of  the 
Leyden  jar,  A,  the  patient's  insulation  is  unnecessary  and  better  effluvation  is  attained.)  S.  M.  is  the 
spark-gap. 


HIGH-FK Kg I" K X < ' V   <  T  I! UK N TS.  149 

affirms  that  currents  of  ten  times  less  intensity  would  be  extremely  dan- 
gerous it'  the  frequency  were  decreased  from  500,000  to  1,000,000  per 
second,  to  100.  Tesla  inclines  to  the  belief  that  the  harmlessiiess  of  these 
currents  is  due  to  their  lack  of  penetration  of  the  body  at  the  point  of 
contact  of  the  electrodes,  but  that  the  current  traverses  the  subject  in  a 
path  perpendicular  to  the  skin  and  equally  over  the  entire  surface. 
])'  Arsonval  declares  that  motor  and  sensory  nerves  are  so  constituted  as 
to  respond  to  vibrations  of  a  certain  frequency,  studying  the  phenomenon 
of  nenro-muscular  excitement  when  one  increases  the  number  of  electrical 
vibrations  indefinitely.  He  has  demonstrated  that  the  waves  (each  of 
which  produces  a  muscular  shock  if  sufficiently  distanced)  no  longer 
produce  the  same  effect  if  there  is  an  augmentation  of  their  number  in 
certain  limits  per  second.  Gradually  there  is  a  fusion  of  the  contrac- 
tions, which  ultimately  results  in  a  tetanized  condition.  In  order  to 
arrive  at  this  condition,  twenty  to  thirty  excitations  per  second  are 
required.  The  muscle  being  tetanized,  if  the  number  of  waves  be 
increased,  the  phenomenon  of  neuro- muscular  excitement  is  increased 
equally  till  a  maximum  is  reached,  which  corresponds  to  2500  or  5000 
vibrations  per  second.  From  this  moment  the  excitation  decreases  as  the 
number  of  vibrations  per  second  increase. 

IV  Arsonval  regards  these  currents  as  inhibitory  in  nature,  because 
of  the  local  anaesthesia  occurring  at  the  point  of  entrance  of  the  current, 
which  lasts  from  one  to  twenty  minutes ;  and  also  that  the  excitability  of 
the  body  to  other  stimulation  is  decreased  under  the  influence  of  these 
currents.  He  has  likewise  observed  a  fall  of  arterial  tension  in  the  dog, 
and  lastly,  that  the  sensibility  of  the  skin  to  galvanism  and  faradism  is 
materially  decreased  after  the  passage  of  high-frequency  currents,  although 
a  greater  strength  of  the  former  currents  can  be  tolerated,  than  before 
electrification. 

VI.   Applications  in  Various  Diseases. 
TUBERCULOSIS. 

Mr.  rhisholm  Williams'  advocates  the  employment  of  high-fre- 
quency currents  in  phthisis.  In  a  series  of  forty-three  cases,  he  found 
that  by  the  use  of  these  currents  there  was  a  marked  improvement  in 
weight,  appetite,  and  digestive  power.  For  a  time  the  temperature 
became  elevated,  and  the  tubercle  bacilli  in  the  sputum  increased  in 
numbers.  Later  the  temperature  dropped  to  normal,  the  bacilli 
decreased,  and  the  patient's  general  condition  was  materially  improved. 
In  1903  thirty-nine  of  the  forty-three  patients  were  alive,  and  in  one 
instance  the  disease  appeared  entirely  arrested.  Dr.  H.  E.  Gamlen* 

1  British  Medical  Journal,  October  12,  1901,  and  October  24,  1903. 
-'  Archives  of  the  Rontgen  Ray,  January,  1906. 


150  ELECTRO-  T 1 1 1 •:  1  I  A  I '  !•:  UTICS. 

likewise  reports  excellent  results,  by  the  use  of  high-frequeiicy  currents 
in  tuberculosis.  Dr.  Alfred  Goss1  remarks  :  "By  the  method  described 
I  have  treated  in  the  past  two  years  a  little  over  two  hundred  cases,  but 
on  account  of  failure  to  keep  my  records  accurately  previous  to  June  1, 
1905,  I  report  my  cases  from  that  time,  and  will  merely  state  in  regard 
to  the  previous  cases  that  I  had  forty-four  cases  out  of  eighty  recover 
within  a  period  of  six  months.  Since  June  1  I  have  one  hundred  and 
seventeen  cases  recorded,  with  thirty-eight  absolute  recoveries  so  far  as 
after  repeated  examinations  no  tubercle  bacilli  showed  in  the  sputum. 
They  regained  their  weight  and  ran  a  normal  temperature.  They  have 
since  been  living  in  various  sections  of  the  country  and  still  remain  well, 
performing  their  usual  avocations.  • ' 

GOUT. 

In  this  disease  high-frequency  currents  alone,  or  in  combination  with 
other  forms  of  electricity,  have  been  employed.  When  used  alone,  auto 
condensation  and  auto- conduction  have  been  chiefly  employed.  These 
currents  must  not  be  applied  during  an  acute  paroxysm.  Low  intensity 
and  brief  duration  of  seances  should  first  be  used,  and  they  should  be 
progressively  increased.  The  treatment  should  be  continuously  applied 
within  short  intervals  for  several  months. 

RHEUMATISM. 

This  affection  has  been  successfully  treated  by  daily  applications 
of  high-frequency  currents  by  means  of  auto-condensation,  seances  of 
ten  minutes'  duration.  At  the  end  of  seven  weeks  the  urine  was  normal, 
treatment  was  stopped,  pain  ceased,  appetite  returned,  and  the  patient 
regained  his  natural  sleep.  In  the  seven  weeks  of  treatment,  his  weight 
increased  6J  pounds.  In  chronic  rheumatism  the  greatest  benefit  is 
derived  from  high-frequency  currents.  The  same  statement  is  vouched 
for  by  Gamlen.1 

OBESITY. 

Foveau  de  Courmelles  was  the  first  to  study  the  effect  of  high- 
frequency  currentvS  on  this  condition.  Boiuet  and  Caillol  de  Poney' 
published  a  report  of  a  series  of  cases  where  the  decrease  in  weight  aver- 
aged 14  pounds  per  month.  All  of  these  cases  were  treated  by  auto-con- 
duction. In  this  class  of  patients,  urinary  findings  show  an  increased 
excretion  of  u  rates  and  phosphates. 

1  Medical  Record,  June  9;  1906. 

'Ibid. 

88oc.  de  Biologie,  July  31,  1897. 


HIGH-FREQUENCY  <  TUKKXTS.  151 

HYSTERIA. 

In  these  cases  the  patient  gains  in  general  condition,  in  weight,  etc. 
The  improvement  noted  is  about  on  a  par  with  the  Weir-Mitchell  rest 
cure.  In  sciatica,  neuralgia,  tabes  dorsalis,  and  chorea,  Gauileu  has 
achieved  excellent  results  with  high-frequency  currents.1 

LUPU8    YULGARIS. 

It  would  appear  that  high-frequency  currents  in  this  disease  behave 
in  a  manner  similar  to  the  X-rays  or  the  Fiuseu  light.  Williams  reports 
that  twenty  applications  of  five  minutes  each,  over  a  period  often  weeks, 
suffice  to  clear  up  any  non-ulcerated  small  patch  of  lupus.  The  effluve, 
the  high-vacuum  glass  electrode  emitting  X-rays,  or  the  ordinary  glass 
electrode  may  be  employed. 

RODENT  ULCER  AND  MALIGNANT  DISEASES. 

In  rodent  ulcer  the  effluve  can  be  readily  and  advantageously  ap- 
plied. In  an  interesting  case  of  that  disease,  Williams  records  how  he  used 
his  thumb  as  an  electrode,  the  patient  being  on  the  auto- condensation 
couch,  and  connected  to  one  pole ;  the  other  was  connected  with  the 
operator,  and  the  circuit  completed  by  the  latter' s  thumb  on  the  ulcer. 
At  the  end  of  the  first  three  applications  the  dry  serum  became  attached 
to  the  thumb;  each  additional  application  seemed  to  shrink  more  of  the 
ulcer.  The  hard  edges,  so  resistant  at  first,  disappeared,  and  for  eleven 
months  there  has  been  no  evidence  of  a  return.  The  applications  are 
painless.  Relapses  are  extremely  rare.  In  1901  Dr.  Allen,  of  Chisle- 
hnrst,2  published  an  elaborate  report  of  malignant  disease  treated  with 
high -frequency  applications.  The  results  he  obtained  were  most  encour- 
aging, some  apparent  cures  being  recorded. 

TILES,  RECTAL  FISSURES,  AND  PRURITUS  ANT. 

In  all  three  of  these  conditions,  high-frequency  currents  have  proved 
most  efficient.  A  special  electrode,  consisting  of  a  stem  with  a  bare  con- 
ical metallic  extremity,  is  employed.  Doumer  has  reported  26  cases  of 
hemorrhoids,  with  more  or  less  successful  results.  Benefit  is  most  pro- 
nounced in  recent  acute  cases,  with  marked  structural  changes.  Mr.  F. 
J.  Bokenham 3  offers  a  summary  of  results  obtained  in  two  years  and  a 
half,  with  currents  of  high  frequency,  in  the  treatment  of  hemorrhoids, 
rectal  fissures,  and  pruritus  ani.  The  number  of  cases  treated  was  118. 
He  records  52  as  completely  cured,  37  as  greatly  relieved,  18  were 
improved,  and  the  remaining  11  he  pronounces  failures.  He  prefers  to 

1  Ibid. 

Mfdieal  Electrology  and  Radiology,  vol.  v.,  page  43. 
3  Lniu-et,  July  '2.  1904. 


152  ELECTRO  -THERAPEUTICS. 

employ  high-vacuum  glass  electrodes.  With  metal  electrodes  he  uses  a 
curreut  of  450  to  500  niilliainperes  ;  with  glass  electrodes,  100  to  150 
milliamperes.  Duration  of  each  seance  about  5  minutes  ;  he  believes 
that  no  one  treatment  should  ever  exceed  15  minutes  in  duration. 

COLITIS. 

Shenton  *  remarks  that  a  valuable  use  of  high-frequency  currents 
consists  in  their  beneficial  effects  in  mucous  and  ulcerative  colitis.  In 
the  first  case  reported  by  the  author,  the  abdomen  was  exposed  almost 
daily  to  weak  X-rays  for  a  month,  but  without  effect.  High-frequency 
treatment  was  then  given  on  the  condenser  couch,  for  a  period  of  ten 
minutes  through  the  hands,  followed  by  a  fifteen-minute  local  applica- 
tion, sometimes  from  the  low  tension  and  sometimes  from  the  resonator. 
This  resulted  in  improvement  of  the  general  condition,  and  gradually  the 
diarrhoaa,  hemorrhage,  and  pain  diminished.  The  treatment  was  con- 
tinued nine  months  and  resulted  in  complete  cure.  Seven  other  cases 
subsequently  treated,  resulted  in  improvement  in  the  general  health, 
increase  in  weight  and  appetite,  and  improvement  in  sleeping.  In  all  of 
the  cases  but  one,  the  results  were  considered  satisfactory. 


Hahn2  used  the  high-frequency  currents  by  means  of  a  special  nasal 
electrode  in  the  treatment  of  ozaeua.  Bordier  and  Collet  in  1902  applied 
high-frequency  currents  in  the  treatment  of  ozsena,  and  since  then  Hahn 
has  used  this  method  in  seven  marked  cases  of  the  disease.  He  used  an 
Oudin  resonator  with  an  electrode  similar  to  that  used  by  Bordier  and 
Collet,  namely,  a  metallic  rod  covered  with  paraffin  or  wax,  and  placed 
in  an  insulating  handle.  The  electrode  may  also  be  enclosed  in  a  glass 
tube,  which  allows  only  the  tip  to  project.  Care  must  be  taken  to  apply 
the  effluvia  to  every  part  of  the  affected  mucosa.  The  smaller  the  sparks, 
the  less  irritation  and  reflex  action  will  there  be.  No  cocaine  or 
adrenalin  was  needed  before  applying  the  high-frequency  current,  but 
the  patient  sneezed  a  few  times  after  the  current  was  turned  on,  com- 
plained of  burning,  slight  pain,  and  lacrymation.  But  these  symptoms 
vanished  in  two  or  three  minutes  if  the  application  was  continued. 
After  three  minutes  the  electrode  was  withdrawn  and  the  patient  was 
asked  to  blow  his  nose,  when  all  the  crusts  usually  came  away  at  once. 
The  stance  was  repeated  in  from  seven  to  forty-eight  hours,  and  lasted 
usually  about  fifteen  minutes,  although  it  can  be  made  twice  as  long  with 
out  harm.  No  other  treatment,  not  even  irrigation,  was  used.  While  the 
author  does  not  allege  absolute  cures  in  his  seven  cases,  the  improvement 

'Archives  of  the  Rontgen  Ray,  August,  1905. 
*Gazzetta  degli  Ospedali,  delle  Cliniche,  March  5,  1905. 


HIGH-FREQUENCY  ( TRRKXTS.  153 

was  very  marked  indeed,  and  the  mucous  membrane  in  some  cases 
assumed  a  more  normal  aspect.  In  all  cases  the  crusts  disappeared  and 
the  odor  Mas  removed,  while  the  subjective  symptoms,  including  the 
headaches,  were  almost  abolished.  He  believes  that  high-frequency  cur- 
rents have  an  antiphlogistic  and  resolvent  action  upon  the  mucosa  of  the 
nose  in  ozaeua. 

EPILEPSY. 

The  following  detailed  reports  of  the  clinical  application  of  high- 
frequency  currents  represent  some  of  the  more  advanced  views  on  the 
therapeutic  value  of  this  agent. 

Concerning  the  treatment  of  epilepsy,  Dr.  Samuel  G.  Tracy '  says : 
' '  The  galvanic  and  faradic  currents  of  electricity  have  been  used  in 
former  years,  but  with  little  success.  If  Hughlings  Jackson's  theories 
regarding  the  nerve  system  are  correct,  it  is  reasonable  to  suppose  that 
high-frequency,  high-potential  electric  currents  will  have  a  beneficial 
effect  on  the  nerve  centres,  and  indirectly  on  epilepsy. 

"As  a  rule  each  patient  should  be  treated  every  other  day,  first 
receiving  X-radiatiou  from  5  to  10  minutes  from  a  high  tube.  This  is 
placed  about  6  to  10  inches  above  the  head,  so  that  the  rays  strike 
directly  upon  the  anterior  and  occipital  part  of  the  brain  (Jackson's 
centres  of  high  level).  After  the  X-radiation  the  patient  should  be  sub- 
jected to  the  influence  of  a  high-frequency  current,  applied  over  the  brain 
for  10  minutes,  and  for  5  minutes  over  the  spine.  In  this  manner  I  have 
treated  the  different  forms  of  epilepsy,  but  I  found  the  best  results  were 
obtained  by  using  the  combined  treatment  of  X-radiatiou  and  high-fre- 
quency currents  with  small  doses  of  bromides.  By  this  latter  method  at 
least  25  per  cent,  of  cases  of  petit  mal  may  be  considered  tentatively  cured, 
20  per  cent,  of  Jacksonian  epilepsy,  and  12  per  cent,  of  grand  mal.  All 
cases  were  improved  more  or  less,  not  only  in  regard  to  the  frequency  of 
the  epileptic  seizures,  but  also  in  regard  to  their  severity.  In  addition  to 
this  the  general  mental  and  physical  condition  was  very  much  improved. 
As  these  experiments  have  been  continued  for  less  than  a  year,  sufficient 
time  has  not  elapsed  to  say  how  much  permanent  value  there  is  to  this 
method  of  treatment.  Nevertheless,  such  progress  has  been  made  in  the 
cases  treated  that  I  believe  we  are  on  the  right  road  to  get  the  best 
results  in  the  treatment  of  epilepsy. 

ikl  am  inclined  to  believe  that  the  high-frequency  currents  have 
some  chemical  effect  on  the  bromide,  possibly  liberating  a  larger  quantity 
of  the  bromide  as  the  solution  of  the  salt  circulates  in  the  brain,  and  thus 
the  drug  in  smaller  quantities  has  a  more  pronounced  therapeutic  effect 
in  controlling  the  epileptic  sei/Aires." 

1  New  York  Medical  Journal,  March  4, 1905. 


154  ELECTRO-THERAPEUTICS. 

SKIN  DISEASES. 

Dr.  Charles  \V.  Allen1  reports  175  cases  of  various  skin  diseases 
treated  siuce  November,  1901.  In  chronic  eczema  he  has  found  the  dis- 
charges of  vacuum  electrodes  of  decided  value  in  alleviating  symptoms 
and  in  diminishing  infiltration.  In  herpes  zoster  of  the  thigh  and  arm 
with  hyperaesthesia  and  neuralgic  pain,  not  only  has  temporary  relief 
been  afforded  immediately  after  each  application,  but  the  whole  course 
of  the  disease  has  been  shortened  and  the  lesions  have  promptly  healed. 

General  effluviatiou  with  metallic  pointed  electrodes,  the  so-called 
11  feather-duster"  brush,  seems  to  diminish  the  pruritus,  to  shorten  the 
attack,  and  decrease  the  duration  of  the  entire  course  in  subacute  and 
persistently  recurring  urticaria.  Dr.  Allen  believes  that  high-frequency 
currents  are  of  decided  advantage  to  those  treating  skin  diseases,  in 
conjunction  with  other  measures.  They  are  curative  of  themselves  in  a 
restricted  class  of  cases  and  efficiently  meet  pruritic  symptoms ;  but  these 
currents  are  inferior  to  the  X-rays  in  skin  diseases,  the  best  work  being 
accomplished  when  they  are  used  conjointly,  as  I  have  frequently  seen. 

TRACHOMA. 

In  the  treatment  of  trachoma,  Stephenson  and  Walsh2  believe  a  prom- 
ising field  has  been  opened  as  a  result  of  their  work  with  the  X-ray 
irradiation  and  the  high-frequency  current. 

In  one  case,  after  22  applications  by  the  high-frequency  current  a  case 
of  trachoma  was  apparently  cured.  A  12-inch  spark-coil  (Cox)  was  run 
from  the  main  connection  with  a  D'Arsonval  high-frequency  apparatus. 
One  end  of  the  solenoid  was  earthed,  while  the  other  was  connected  with 
a  vulcanite  electrode,  with  which  the  closed  eyelids  were  gently  massaged. 
A  small  brush  discharge  of  about  half  an  inch  was  obtainable  from  the 
electrode,  which  would  probably  have  acted  upon  the  trachoma  equally  as 
well  without  actual  contact  of  the  electrode  with  the  lids.  So  far  as  can 
be  ascertained,  this  is  the  first  application  of. the  high-frequency  current 
to  the  eye.  By  this  means,  as  with  the  focus  tube,  more  improvement 
has  been  effected  than  could  have  been  expected  from  the  prolonged  use 
of  escharotics. 

DULNESS  OF  HEARING  AND  SUBJECTIVE  NOISES. 

Dr.  ,T.  G.  ConnaP  says  in  reference  to  dulness  of  hearing  and  the 
occurrence  of  subjective  noises  :  "The  cases  were  of  a  class  not  readily 
influenced  by  ordinary  methods  of  treatment.  The  types  selected  were  : 
(1)  chronic  dry  catarrh  of  the  middle  ear  with  secondary  labyrinthine 

1  Medical  Record,  February  20,  1904. 

*  Medical  Press  and  Circular,  No.  7;  Progress  of  Medical  Science,  1903. 

'Journal  of  Laryngology  and  Rhinology,  August,  1904. 


HK i H-F  1 1  K(  v>  r  i •: x <  •  v  r r KKEXTS.  i  .*,.-, 

involvement ;  (2)  chronic  dry  catarrh  of  the  middle  ear  without  marked 
labyrinthine  involvement:  •">  ^clerosis  of  the  middle  ear;  (4)  post- 
suppurative  conditions  of  the  middle  ear  (the  purulent  process  having 
ceased ).  leaving  a  cicatrix  or  a  dry  perforation  with  or  without  cal- 
careous deposit  in  the  tympanic  membrane  ;  (5)  primary  labyrinthitis 
;  traumatic);  (6)  tinnitus  without  duluess  of  hearing.  In  all  the  cases 
both  ears  were  involved,  one  ear  generally  being  worse  than  the  other. 
Results  :  1.  Six  cases.  Xo  improvement  in  the  hearing  of  any  of 
them.  In  four  the  tinnitus  persisted  ;  two  thought  the  noises  were  slightly 
lessened,  but  were  not  at  all  certain.  2.  Fourteen  cases.  In  ten,  no 
improvement  in  hearing;  one  was  worse  ;  two  noted  a  slight  improve- 
ment in  the  hearing.  One  patient  said  she  heard  much  better,  but  the 
improvement  was  not  appreciable  by  the  tests  applied.  Of  the  ten 
patients  who  complained  of  tinnitus,  eight  reported  an  improvement ; 
two  of  these  said  they  were  very  much  better.  In  one  case  the  noise  dis- 
appeared entirely  in  one  ear  for  six  weeks,  when  it  recurred.  3.  Five 
cases.  One  patient  said  she  heard  better,  but  did  not  respond  to  tests  ; 
four  reported  an  improvement  in  the  hearing,  confirmed  with  the  watch, 
and  improvement  in  the  tinnitus.  4.  Seven  cases.  Four  reported  a 
slight  improvement  in  hearing,  and  four  or  five  who  had  tinnitus  reported 
improvement.  5.  One  case.  No  benefit.  6.  One  case.  No  benefit. 
The  author  urges  the  importance  of  techuic  in  the  electrical  treatment  of 
these  cases.  The  common  method  of  applying  the  current  is  by  means 
of  the  effluve  (spray).  This  method  was  adopted  in  the  earlier  cases, 
but  was  found  unsatisfactory.  The  method  of  using  a  condenser  elec- 
trode in  each  ear  was  substituted  and  gave  better  results,  probably 
because  the  cm-rent  is  more  completely  concentrated  on  the  ears. 

GONORRHCEA. 

Gamlen  l  treated  a  rebellious  case  of  gonorrhoea  by  high-frequency 
currents,  by  means  of  a  bougie  connected  with  the  terminal  on  the  top  of 
the  resonator.  At  the  same  time,  general  high-frequency  currents  were 
administered.  Sixteen  of  these  combined  treatments  effected  a  cure. 
Local  treatment  was  given  every  second  day;  duration  of  each  treatment 
was  five  minutes.  He  also  mentions  the  case  of  a  young  woman,  with  a 
history  of  gonorrhoea  of  three  weeks'  duration.  The  usual  medicinal 
treatment  proved  futile;  high-frequency  treatment  was  instituted  and  a 
vaginal  glass  electrode  was  employed.  "After  the  first  few  applications,'' 
saysGamleu.  "the  irritation,  and  later  the  discharge,  gradually  subsided. 
Fourteen  applications  effected  a  complete  cure." 

1  Archives  of  the  Rontgen  Ray,  February,  1906. 


PART    II 

THE  RONTGEN    RAYS  IN  DIAGNOSIS 


Historical  Introduction. 

THE  discoveries  made  and  the  achievements  wrought  in  the  domain 
of  electricity  are  the  recorded  efforts  of  determined  and  conscientious 
minds  of  all  ages.  From  the  remotest  periods  of  the  world's  history  the 
mysterious  phenomena  of  electricity  have  arrested  attention  and  invited 
thought  from  searching  inquirers,  and  slowly  but  surely  the  hidden 
secrets  of  this  subtle  force  of  nature  have  been  steadily  unfolded,  until 
to-day  the  mighty  achievements  ascribable  to  it  confront  us  on  every  side, 
offering  a  telling  contrast  to  the  methods  pursued  a  few  centuries  ago, 
when  men  with  crude  appliances  and  still  cruder  ideas  led  the  van  in  ex- 
perimental inquiry. 

To  Otto  von  Guericke,  the  world  owes  a  debt  of  gratitude  for  his 
successful  labors  in  inventing,  in  1650,  the  air-pump  and  in  ingen- 
iously applying  it  to  the  laws  of  science.  In  1740  Abbe  Nollet  em- 
ployed the  air-pump  and  continued  the  studies  commenced  by  von 
Guericke.  It  remained  for  Sir  W.  Snow  Harris,  in  1834,  to  formulate 
boldly  the  statement,  that  the  length  of  the  spark  which  an  electric 
machine  will  give  in  the  air  varies  as  the  inverse  ratio  of  the  pressure  of 
the  gas. 

In  1838,  the  immortal  Faraday  challenged  the  world' s  admiration 
with  his  experiments  in  electricity,  and  simultaneously  his  celebrated 
confrere,  Heinrich  Geissler,  made  memorable  that  scientific  epoch,  by  im- 
proving on  the  efforts  of  Faraday  in  his  study  of  electric  glow  discharges. 
The  principles  of  and  the  laws  governing  electric  science  were  being 
surely  evolved,  when  in  1840  Clerk  Maxwell  turned  the  search-light  on 
this  special  department  of  science,  and  gave  to  the  world  the  electro- 
magnetic theory  of  light. 

Sir  William  Thomson  (now  Lord  Kelvin),  not  unmindful  of  the 
laborious  researches  of  Sir  W.  Snow  Harris,  determined  to  make  a  pro- 
found study  of  the  relation  existing  between  gas  pressure  and  spark 
length,  and  in  1860  he  gave  to  science  the  absolute  electrometer,  an  in- 
vention that  at  once  brought  his  name  into  commanding  prominence. 
The  substitution  of  the  Euhmkorff  coil  by  cells  was  the  very  original 
thought  that  occupied  the  attention  of  Gassiot.  With  a  battery  con- 
sisting of  more  than  3500  cells,  this  celebrated  French  physicist  proved 
156 


THE  ROXTGEX  RAYS  IX  DIAGNOSIS.  157 

conclusively  that  a  vacuum  tube  glowed  incessantly  when  placed  in  the 
path  of  its  circuit,  and  in  1865,  Hermann  Spreugel  invented  the  mercury 
air-pump,  an  instrument  devised  for  tin-  purpose  of  producing  very  high 
rarefactions,  with  a  great  degree  of  rapidity. 

In  1869,  Hittorf  s  name  became  familiar  for  experimentations  along 
these  lines,  and  the  same  work  was  largely  followed  by  Goldstein  in  1876. 
It  was  during  the  latter  year  that  the  brilliant  researches  of  Gassiot  were 
being  still  further  prosecuted.  In  1877.  a  coterie  of  scientists  were  eager 
to  take  up  the  work  where  Gassiot  had  left  off;  not  the  least  conspic- 
uous among  these  were  Warren  de  la  Rue,  Hugo  Miiller.  and  W.  Spottis- 
woode. 

From  1877  to  1879,  investigators  were  making  extended  studies  and 
investigations  into  the  theories  already  advanced,  and  perfecting  with 
unremitting  energy  the  practical  points  previously  deduced.  In  the 
latter  year  the  celebrated  Sir  AVilliam  Crookes  startled  the  world  by  his 
announcement  that  matter  was  radiant.  It  was  he  who  declared  that  the 
particles  that  were  shot  off  from  the  cathode  ray  possessed  strange  and 
remarkable  properties. 

In  1883,  "Wiedemauu  and  J.  J.  Thomson  continued  these  studies  and 
declared  these  particles  to  be  ether  disturbances  of  very  short  wave 
length.  The  study  was  continued  by  Professor  Hertz  at  Bonn,  leading 
to  an  investigation  of  high  vacua  discharge  experiments.  The  work  was 
continued  by  his  assistant,  Professor  Leuard,  who  in  1894  proved  the 
possibility  of  cathode  rays  passing  through  the  walls  of  a  vacuum  tube. 
Perrin,  in  France,  and  Elster  and  Geitel  in  Germany,  made  searching 
studies  into  the  latter  subject. 

It  was  in  1895,  that  Professor  Rontgeu  was  experimenting  with 
Leuard  and  Crookes  tubes  when  an  unusual  phenomenon  met  his  gaze. 
His  tube  was  completely  enveloped  in  an  opaque  cover,  wheu  a  near-by 
paper  containing  a  fluorescent  substance  exhibited  a  most  pronounced 
visible  glow  !  How  could  the  phenomenon  be  explained  ?  The  rays 
offered  a  triumphant  resistance  to  the  action  of  the  magnet.  These  were 
the  rays  so  indispensable  to  the  photographers  art;  the  rays  that  were 
destined  to  revolutionize  many  preconceived  notions  in  medicine  and 
surgery.  A  new  radiation  had  burst  forth  at  the  touch  of  genius  ;  a  new 
science  had  come  into  being. 

Wilhelm  Conrad  Rontgeu  was  born  in  Leuuep,  Province  of  the 
Rhine,  Germany,  March  27,  1845.  At  an  early  age  the  boy  showed  a 
remarkable  aptitude  for  study,  and  in  1870  he  was  graduated  as  a  Doctor 
of  Philosophy  from  the  University  of  Zurich.  Seeing  that  the  youth 
gave  promise  of  a  bright  career,  Professor  Kundt  took  a  lively  interest 
in  the  young  man,  and  in  1873,  when  Kuudt  was  elected  to  a  chair  at  the 
University  of  AViirzburg,  the  young  scientist  accompanied  him,  and  at 


l.-..s  ELECTRO-THERAPEUTICS. 

Professor  K limit's  promotion  to  the  University  of  Strasburg,  Professor 
Rontgen  became  his  assistant.  In  1875,  Professor  Routgeu  was  made 
Professor  of  Mathematics  and  Physics  in  the  Agricultural  Academy  at 
Hohenheim,  retiring  from  the  institution  to  return  to  Strasbnrg  just 
one  year  later.  In  1870,  he  accepted  a  call  as  Professor  and  also  as  a 
Director  of  the  Department  of  Physics  at  the  University  of  Giesseu  ;  he 
likewise  accepted  a  similar  position  at  the  University  of  Wiirzbnrg.  — 
the  latter  office  he  still  holds. 

The  labors  of  Professor  Rontgen  have  been  manifold  ;  he  has  had 
published  his  investigations  on  isothermal  crystals,  solar  ealorimetry, 
dust  figures,  aneroid  barometry,  absorption  of  heat  by  various  vapors, 
etc.  During  the  past  decade  his  studies  have  been  almost  exclusively 
devoted  to  problems  in  electricity.  Space  forbids  naming  even  a  tithe  of 
the  honors  that  have  been  showered  upon  this  celebrated  scientist.  Re- 
quested by  the  German  Emperor  to  demonstrate  his  discovery  at  the 
Palace  at  Potsdam,  the  Emperor  decorated  him  with  a  Crown  Order  of 
the  Second  Class.  The  University  of  Munich  presented  him  with  a  pro- 
fessorship in  recognition  of  his  immortal  discovery.  He  was  awarded 
the  Barnard  medal  from  the  National  Academy  of  Sciences  at  the  com- 
mencement exercises  of  Columbia  University,  New  York  City,  and  he 
also  received  the  Nobel  prize  in  1901. 

The  Comparative  Study  of  the  Properties  of  the  Cathode  and  the 
Rontgen  Rays. 

CATHODE  RAYS. 

Production. — Much  discussion  has  arisen  as  to  the  true  character  of  the 
cathode  rays.  One  school  of  philosophers  declare  that  they  are  not  rays 
of  light,  but  merely  a  stream  of  molecules  proceeding  from  the  cathode ; 
others  adhere  to  the  view  that  these  rays  are  analogous  to  ordinary  light 
rays,  and  represent  some  process  occurring  in  the  atmospheric  ether. 
Nevertheless  the  fact  remains  that,  for  their  production,  it  is  essential  to 
have  a  certain  degree  of  vacuum  in  the  tube.  If  this  degree  of  vacuum 
be  increased,  the  production  of  cathode  rays  is  no  longer  possible,  and 
when  the  tube  is  as  completely  exhausted  as  is  possible,  the  production  of 
X-rays  occurs.  Cathode  rays  can  be  produced  only  within  the  walls  of 
the  glass  tube,  and  must  be  studied  outside  of  the  tube  by  the  introduc- 
tion of  Lenard's  aluminium  window. 

Radidbiliiy. — Professor  Hertz  was  the  first  to  demonstrate  authorita- 
tively that  thin  sheets  of  metal  were  transradiable,  and  Leuard  showed 
the  phenomenon  to  be  true  of  thin  layers  of  other  substances  opaque  to 
light.  Gold,  silver,  and  aluminium  foil  allowed  the  passage  of  the  rays 
without  suffering  loss  of  any  of  their  intensity.  With  gases,  it  was  found 


THE  ROXTGEN   KAYS  IX  DIAGNOSIS.  159 

that  the  power  of  penetration  varied  inversely  as  the  density, — /.  e.,  the 
greater  the  density  the  less  the  penetrability.  Water  was  found  to  be 
transradiable  only  in  extremely  thin  strata. 

Fluorescence  and  Phosphorescence. — Experimentation  has  proved  that 
the  phosphides  of  the  alkaline  earths,  calc  spar,  and  uranium  glass  glow 
brilliantly  when  near  the  aluminium  window.  Salts  of  manganese,  cad- 
mium, strontium,  and  lithium  luminesce  brightly.  Liquids  are  inactive. 
A  rather  curious  fact  is,  that  the  sulphate  of  quinine  in  solution  is  only 
slightly  excited,  but  the  same  salt  in  the  solid  state  offers  a  most  bril- 
liant glow  of  a  deep  blue  color.  Lenard  affirms  that  the  platino- cyanides 
exhibit  colors,  similar  to  those  that  are  produced  under  the  influence  of 
the  ultra-violet  rays. 

Reflection,  Refraction,  and  Polarization. — In  the  vacuum  tube  the 
cathode  rays  appear  to  be  reflected  and  to  behave  in  the  same  manner  as 
rays  of  light.  Nothing  definite  has  been  determined  regarding  the  polar- 
ization of  these  rays. 

Chemical  and  Photographic  Effects. — The  cathode  rays  possess  a  most 
energetic  chemical  action  on  the  alkaline  haloids,  and  on  some  of  the 
haloids  of  the  earths.  Thus  lithium  chloride  suffers  a  change  to  violet, 
whilst  sodium  chloride  can  be  made  to  change  to  either  a  yellow  or  a  gray 
color.  Upon  heating,  the  former  is  converted  into  a  red  color ;  the  latter 
blue.  The  cathode  rays  act  energetically  on  photographic  papers  and 
plates ;  thus  iodine  paper  is  quickly  converted  to  a  pronounced  blue  on 
exposure  to  the  rays. 

Physiological  Effects.  — Neither  the  eye  nor  the  skin  is  affected  by  the 
action  of  the  cathode  ray;  a  characteristic  odor  and  taste  are  produced, 
but  by  some  authorities  these  are  ascribed  to  the  presence  of  ozone. 

Theories. — The  theories  advanced  to  explain  the  cathode  rays  are  the 
hypotheses  put  forth  by  the  leading  exponents  of  the  English  and  German 
schools  of  philosophers.  The  former  physicists  incline  to  the  belief  that 
the  cathode  rays  are  streams  of  electrified  molecules  that  are  shot  off  from 
the  cathode ;  in  contradistinction  to  the  German  scientists,  who  hold  that 
Hirst-  rays  are  manifestations  of  ethereal  vibrations;  defending  this  state- 
ment with  the  results  of  Lenard' s  investigations,  and  declaring,  with  that 
scientist,  that  cathode  rays  are  propagated  through  a  vacuum  in  straight 
lines,  and  so  void  of  all  matter  that  through  them  an  electric  spark  can- 
not be  made  to  pass. 

Jaumann's  theory,  which  brings  into  the  discussion  the  subject  of 
longitudinal  waves,  has  received  some  support.  He  asserts  that  when 
these  rays  are  incident  at  right  angles  there  is  caused  a  high  discharging 
effect,  showing  a  large  longitudinal  component.  This  theory  gains  cor- 
roboration  in  a  magnetic  field.  In  accordance  with  this  investigator's 
views,  these  rays  can  only  be  normally  reflected  when  the  force  applied 


160  ELECTRO-THERAPEUTICS. 

is  parallel  to  the  reflecting  surface.  Space  forbids  the  presentation  of 
many  other  ingenious  theories,  advanced  by  Wiedeiiiaim,  Hertz,  Gold- 
stein, Prout,  and  J.  J.  Thomson. 

RONTGEX  RAYS. 

Production. — The  new  radiation — that  form  of  energy  called  the 
Rontgeu  rays  or  the  X-rays,  requires  for  its  production  a  highly  exhausted 
discharge  tube.  It  must  be  borne  in  mind  that  the  essential  factor  in  the 
generation  of  the  Routgeu  rays  is  that  the  electric  discharge  must  be  made 
to  take  place  in  a  high-vacuum  tube,  such  as  the  Crookes  tube;  other 
circumstances,  as  the  character  of  the  coil  or  dynamo,  being  matters  of 
minor  consideration.  Again,  if  we  take  Geissler  tubes,  which  are  bulbs 
in  which  the  air  is  only  partially  exhausted,  we  obtain  what  is  known 
as  a  low  vacuum,  and  it  is  difficult,  or  indeed  impossible,  to  generate 
Rontgeu  rays  from  such  a  discharge  apparatus.  The  Routgeu  rays  re- 
quire the  one-millionth  part  of  atmospheric  pressure. 

Radiability  and  Penetrability. — The  peculiar  power  possessed  by  the 
Routgen  rays,  of  penetrating  substances  opaque  to  ordinary  light  or 
cathode  rays,  has  been  shown  by  Professor  Routgeu  to  be  largely  de- 
pendent upon  the  relative  density  and  thickness  of  the  substance  under 
examination.1  In  an  elaborate  exposition  in  his  first  communication, 
he  says: 

"Sheets  of  hard  rubber  several  centimetres  thick  still  permit  the 
rays  to  pass  through  them.  Glass  plates  of  equal  thickness  behave  quite 
differently,  according  as  they  contain  lead  (flint-glass)  or  not;  the  former 
are  much  less  transparent  than  the  latter.  If  the  hand  be  held  between 
the  discharge  tube  and  the  screen,  the  darker  shadow  of  the  bones  is  seen 
within  the  slightly  dark  shadow-image  of  the  hand  itself.  Water,  carbon 
disulphide,  and  various  other  liquids,  when  they  are  examined  in  mica 
vessels,  seem  also  to  be  transparent.  That  hydrogen  is  to  any  considera- 
ble degree  more  transparent  than  air,  I  have  not  been  able  to  discover. 
Behind  plates  of  copper,  silver,  lead,  gold,  and  platinum  the  fluores- 
cence may  still  be  recognized,  though  only  if  the  thickness  of  the  plates 
is  not  too  great.  Platinum  of  a  thickness  of  0. 2  mm.  is  still  transparent ; 
the  silver  and  copper  plates  may  even  be  thicker.  Lead  of  a  thickness 
of  1.5mm.  is  practically  opaque ;  and  on  account  of  this  property  this 
metal  is  frequently  most  useful.  A  rod  of  wood  with  a  square  cross- 
sect  ion  (20  x  20  mm.),  one  of  whose  sides  is  painted  white  with  lead 
paint,  behaves  differently  according  as  to  how  it  is  held  between  the 

1  In  this  and  the  succeeding  paragraphs  the  quotations  have  been  taken  from 
"  Rontgen  Rays;''  embracing  Professor  Rontgen's  original  communications  to  the 
Physikalisches  Institut  der  Universitiit,  of  Wiirzburg,  and  translated  by  George  F. 
Barker,  LL.D.;  Harper  and  Brothers,  Publishers. 


THE  ROXTGEX  RAYS  IX  DIAGNOSIS.  161 

apparatus  and  the  screen.  It  is  almost  entirely  without  action  when  the 
X-rays  pass  through  it  parallel  to  the  painted  side:  whereas  the  stick 
throws  a  dark  shadow  when  the  rays  are  made  to  traverse  it  perpendicular 
to  the  painted  side.  In  a  series  similar  to  that  of  the  metals  themselves, 
their  salts  can  be  arranged  with  reference  to  their  transparency,  either 
in  the  solid  form  or  in  solution. 

uThe  experimental  results  which  have  now  been  given,  as  well  as 
ot  hers,  lead  to  the  conclusion  that  the  transparency  of  different  substances, 
assumed  to  be  of  equal  thickness,  is  essentially  conditioned  upon  their 
density  ;  no  other  property  makes  itself  felt  like  this,  certainly  to  so  high 
a  degree. 

"The  following  experiments  show,  however,  that  the  density  is  not 
the  only  cause  acting.  I  have  examined,  with  reference  to  their  trans- 
parency, plates  of  glass,  aluminium,  calcite,  and  quartz,  of  nearly  the 
same  thickness;  and  while  these  substances  are  almost  equal  in  density, 
yet  it  was  quite  evident  that  the  calcite  was  sensibly  less  transparent  than 
the  other  substances,  which  appeared  almost  exactly  alike.  Xo  particu- 
larly strong  fluorescence  of  calcite,  especially  by  comparison  with  glass, 
has  been  noticed. 

"  All  substances  with  increase  in  thickness  become  less  transparent. 
In  order  to  find  relation  between  transparency  and  thickness,  I  have 
made  photographs  in  which  portions  of  the  photographic  plate  were 
covered  with  layers  of  tin-foil,  varying  in  the  number  of  sheets  super- 
posed. Photometric  measurements  of  these  will  be  made  when  I  am  in 
possession  of  a  suitable  photometer. 

"  Sheets  of  platinum,  lead,  zinc,  and  aluminium  were  rolled  of  such 
thickness  that  all  appeared  nearly  equally  transparent.  The  following 
table  contains  the  absolute  thickness  of  these  sheets  measured  in  milli- 
metres, the  relative  thickness  referred  to  that  of  the  platinum  sheet,  and 
their  densities : 


Thickness. 
Pt  0  018  mm     . 

Relative  Thickness. 
.    .                                                 1 

Density. 
21.5 

Pb  0.05     mm  

3 

11.3 

Zn  0.10    mm  

a 

7.1 

Al    3.5      mm. 

.  200 

2.6 

* '  We  may  conclude  from  these  values  that  different  metals  possess 
transparencies  which  are  by  no  means  equal,  even  when  the  product  of 
thickness  and  density  are  the  same.  The  transparency  increases  much 
more  rapidly  than  this  product  decreases." 

Fluorescence  ninl  Pfu>9pkor«9oenoe, — In  his  lirst  communication  Pro- 
fessor Routgeu  discourses  at  length  on  the  fluorescent  effects  of  the  new 
ray.  and  states  its  effect  on  barium  platiuo-cyanide,  calcium  sulphide,  etc. 
11 


162  ELECTRO-T 1 1 K II A P I •: r T I <  'S. 

The  amount  and  color  of  the  radiations  emitted  would  seem  to  be  entirely 
dependent  upon  the  character  of  the  substance  under  examination.  In 
this  connection  he  wrote  : 

"  If  the  discharge  of  a  fairly  large  induction  coil  be  made  to  pass 
through  a  Hittorf  vacuum-tube,  or  through  a  Lenard  tube,  a  Crookes 
tube,  or  other  similar  apparatus  which  has  been  sufficiently  exhausted, 
the  tube  being  covered  with  thin,  black  card-board  which  fits  it  with  tol- 
erable closeness,  and  if  the  whole  apparatus  be  placed  in  a  completely 
darkened  room,  there  is  observed  at  each  discharge  a  bright  illumination 
of  a  paper  screen  covered  with  barium  platino-cyanide,  placed  in  the 
vicinity  of  the  induction  coil,  the  fluorescence  thus  produced  being  en- 
tirely independent  of  the  fact  whether  the  coated  or  the  plain  surface  is 
turned  toward  the  discharge  tube.  This  fluorescence  is  visible  even  when 
the  paper  screen  is  at  a  distance  of  two  metres  from  the  apparatus.  It  is 
easy  to  prove  that  the  cause  of  the  fluorescence  proceeds  from  the  dis- 
charge apparatus,  and  not  from  any  other  point  in  the  conducting  circuit. 

'"  The  most  striking  feature  of  this  phenomenon  is  the  fact  that  an 
active  agent  here  passes  through  a  black  card-board  envelope,  which  is 
opaque  to  the  visible  and  the  ultra-violet  rays  of  the  sun  or  the  electric 
arc  ;  an  agent,  too,  which  has  the  power  of  producing  .active  fluorescence. 
Hence  we  may  first  investigate  the  question  whether  other  bodies  also 
possess  this  property. 

"We  soon  discover  that  all  bodies  are  transparent  to  this  agent, 
though  in  very  different  degrees.  I  proceed  to  give  a  few  examples : 
Paper  is  very  transparent ;  behind  a  bound  book  of  about  one  thousand 
pages  I  saw  the  fluorescent  screen  light  up  brightly,  the  printer's  ink  of- 
fering scarcely  a  noticeable  hinderauce.  In  the  same  way  the  fluorescence 
appeared  behind  a  double  pack  of  cards;  a  single  card  held  between  the 
apparatus  and  the  screen  behind  being  almost  imuoticeable  to  the  eye. 
A  single  sheet  of  tin-foil  is  also  scarcely  perceptible ;  it  is  only  after' sev- 
eral layers  have  been  placed  over  one  another  that  their  shadow  is  dis- 
tinctly seen  on  the  screen.  Thick  blocks  of  wood  are  also  transparent, 
pine  boards  two  or  three  centimetres  thick  absorbing  only  slightly.  A. 
plate  of  platinum  about  fifteen  millimetres  thick,  though  it  enfeebles  the 
action  seriously,  did  not  cause  the  fluorescence  to  disappear  entirely. 

«     *    *    *    *    The  fluorescence  of  barium  platino-cyanide  is  not, 
the  only  recognizable  effect  of  the  X-rays.     It  should  be  mentioned  that 
other  bodies  also  fluoresce;   such,  for  instance,  as  the  phosphorescent 
calcium  compounds,  then  uranium  glass,  ordinary  glass,  calcite,  rock-salt. 
and  so  on." 

Reflection,  Refraction,  Pohn-izatlon,  «n<1  Int<  rfrrencc. — The  earlier  ef- 
forts made,  tended  to  show  that  the  Bontgen  rays  defied  reflection,  but 
later  investigations  have  conclusively  proved  that  a  reflection,  similar  to 


THK   BONTGEN  KAYS  IX  DIAGNOSIS.  163 

that  diffuse  reflection  obtained  from  the  surface  of  ground  glass,  could  be 
demonstrated.  It  lias  likewise  been  shown  that  reflection  is  largely  de- 
pendent on  the  character  of  the  substance  composing  the  surface.  More 
recently  Carmichael,  of  Lille,  succeeded  in  reflecting  X-rays  through  the 
agency  of  steel  mirrors.  The  value  of  his  experiment  has  not  been  deter- 
mined. In  his  first  paper  upon  the  X-rays  Professor  Kontgeu  said  : 

••  After  I  had  recognized  the  transparency  of  various  substances  of 
relatively  considerable  thickness,  I  hastened  to  see  how  the  X-rays  be- 
haved on  passing  through  a  prism,  and  to  find  out  whether  they  were 
thereby  deviated  or  not. 

"Experiments  with  water  and  with  carbon  distil phide  enclosed  in 
mica  prisms  of  about  30°  refracting  angle  showed  no  deviation,  either 
with  the  fluorescent  screen  or  on  the  photographic  plate.  For  purposes 
of  comparison,  the  deviation  of  rays  of  ordinary  light  under  the  same 
conditions  was  observed  :  and  it  was  noted  that  in  this  case  the  deviated 
images  fell  on  the  plate  about  10  or  20  millimetres  distant  from  the  direct 
image.  By  means  of  prisms  made  of  hard  rubber  and  aluminium,  also  of 
about  30°  refracting  angle,  I  have  obtained  images  on  the  photographic 
plate  in  which  some  small  deviation  may  perhaps  be  recognized.  How- 
ever, the  fact  is  quite  uncertain  ;  the  deviation,  if  it  does  exist,  being  so 
small  that  in  any  case  the  refractive  index  of  the  X-rays  in  the  substances 
named  cannot  be  more  than  1.05  at  the  most.  With  the  fluorescent 
screen  I  was  also  unable  to  observe  any  deviation. 

"Up  to  the  present  time  experiments  with  prisms  of  denser  metals 
have  given  no  definite  results,  owing  to  their  feeble  transparency  and 
the  consequently  diminished  intensity  of  the  transmitted  rays. 

' '  With  reference  to  the  general  conditions  here  involved  on  the  one 
hand,  and  on  the  other  to  the  importance  of  the  question  whether  the 
X-rays  can  be  refracted  or  not  on  passing  from  one  medium  into  another, 
it  is  most  fortunate  that  this  subject  may  be  investigated  in  still  another 
way  than  with  the  aid  of  prisms.  Finely  divided  bodies  in  sufficiently 
thick  layers  scatter  the  incident  light  and  allow  only  a  little  of  it  to  pass, 
owing  to  reflection  and  refraction  ;  so  that  if  powders  are  as  transparent 
to  X-rays  as  the  same  substances  are  in  mass — equal  amounts  of  ma- 
terial being  presupposed — it  follows  at  once  that  neither  refraction  nor 
regular  reflection  takes  place  to  any  sensible  degree.  Experiments 
were  tried  with  finely  powdered  rock  salt^  with  fine  electrolytic  silver 
powder,  and  with  zinc  dust,  such  as  is  used  in  chemical  investigations. 
In  all  these  cases  no  difference  was  detected  between  the  transparency  of 
the  powders  and  that  of  the  substance  in  mass,  either  by  observation 
with  the  fluorescent  screen  or  with  the  photographic  plate. 

"From  what  has  now  been  said  it  is  obvious  that  the  X-rays  cannot 
be  concentrated  by  lenses  ;  neither  a  large  lens  of  hard  rubber  nor  a  glass 


164  ELECTRO-THKRAI'KITK  S. 

leiis  having  any  influence  upon  them.  The  shadow-picture  of  a  round 
rod  is  darker  in  the  middle  than  at  the  edge  ;  while  the  image  of  a  tube 
which  is  filled  with  a  substance  more  transparent  than  its  own  material  is 
lighter  at  the  middle  than  at  the  edge. 

11  The  question  as  to  the  reflection  of  the  X-rays  may  be  regarded  as 
settled,  by  the  experiments  mentioned  in  the  preceding  paragraph,  in 
favor  of  the  view  that  no  noticeable  regular  reflect  ion  of  the  rays  takes 
place  from  any  of  the  substances  examined.  Other  experiments,  which  I 
here  omit,  lead  to  the  same  conclusion. 

a  #  #  #  *  if  we  compare  this  fact  with  the  observation  already 
mentioned,  that  powders  are  as  transparent  as  coherent  masses,  and  with 
the  further  fact  that  bodies  with  rough  surfaces  behave  like  polished 
bodies  with  reference  to  the  passage  of  the  X-rays,  as  shown  also  in  the 
last  experiment,  we  are  led  to  the  conclusion  already  stated  that  regular 
reflection  does  not  take  place,  but  that  bodies  behave  toward  the  X-rays 
as  turbid  media  do  toward  light. 

11  Since,  moreover,  I  could  detect  no  evidence  of  refraction  of  these 
rays  in  passing  from  one  medium  to  another,  it  would  seem  that  X-rays 
move  with  the  same  velocity  in  all  substances;  and,  further,  that  this 
speed  is  the  same  in  the  medium  which  is  present  everywhere  in  space 
and  in  which  the  particles  of  matter  are  imbedded.  These  part  ides  hin- 
der the  propagation  of  the  X-rays,  the  effect  being  greater,  in  general, 
the  more  dense  the  substance  concerned. 

"  Accordingly  it  might  be  possible  that  the  arrangement  of  particles 
in  the  substance  exercised  an  influence  ou  its  transparency  ;  that,  for  in- 
stance, a  piece  of  calcite  might  be  transparent  in  different  degrees  for  the 
same  thickness,  according  as  it  is  traversed  in  the  direction  of  the  axis, 
or  at  right  angles  to  it.  Experiments,  however,  ou  calcite  and  quartz 
gave  a  negative  result." 

Sir  G.  G.  Stokes,1  "The  Wild  Lecture,"  lucidly  says  :  "Everything 
tends  to  show  that  these  rays  are  something  which,  like  rays  of  light, 
are  propagated  in  the  ether.  What,  then,  is  the  nature  of  this  process 
going  on  in  the  ether  1  Some  of  the  properties  of  the  Eoutgeu  rays 
are  very  surprising,  and  very  unlike  what  we  would  be  in  the  habit 
of  considering  with  regard  to  rays  of  light.  One  of  the  most  strik- 
ing things  is  the  facility  with  which  they  go  through  bodies  which  are 
utterly  opaque  to  light,  such,  for  example,  as  black  paper,  board,  and 
so  forth.  If  that  stood  alone  it  would  not,  perhaps,  constitute  a  very 
important  difference  between  them  and  light.  A  red  glass  will  stop 
green  rays  and  let  red  rays  through  ;  and  just  in  the  same  way  if  the 
Rontgeu  rays  were  of  the  nature  of  the  ordinary  rays  of  light,  it  is 
possible  that  a  substance,  although  opaque  to  light,  might  be  transparent 

1  Ibid. 


THE  ROXTGEN   KAYS  IX  DIAGNOSIS.  ]<;.-, 

to  them.  So,  as  I  say,  that  remarkable  property,  it'  it  stood  alone, 
would  not  necessarily  constitute  any  great  difference  of  nature  between 
them  and  ordinary  light. 

it,  *  #  #  *  jjut  there  are  other  properties  which  are  far  more 
difficult  to  reconcile  with  the  idea  that  the  Rontgen  rays  are  of  the  nature 
of  light.  There  is  the  absence,  or  almost  complete  absence,  of  refraction 
and  reflection.  Another  remarkable  property  of  these  rays  is  the  extreme 
sharpness  of  the  shadows  which  they  cast  when  the  source  of  the  rays  is 
made  sufficiently  narrow.  The  shadows  are  far  sharper  than  those  pro- 
duced under  similar  circumstances  by  light,  because  in  the  case  of  light 
the  shadows  are  enlarged  as  the  effect  of  diffraction.  This  absence  or 
almost  complete  absence  of  diffraction  is,  then,  another  circumstance 
distinguishing  these  rays  from  ordinary  rays  of  light.  In  face  of  these 
remarkable  differences,  those  who  speculated  with  regard  to  the  nature 
of  the  rays  were  naturally  disposed  to  look  in  a  direction  in  which  there 
was  some  distinct  difference  from  the  process  which  we  conceive  to  go  on 
in  the  propagation  and  production  of  ordinary  rays  of  light.  Those  who 
have  speculated  on  the  dynamical  theory  of  double  refraction  have  been 
led  to  imagine  the  possible  existence  in  the  ether  of  longitudinal  vibra- 
tions, as  well  as  those  transversal  vibrations  which  we  know  to  constitute 
light.  If  we  were  to  suppose  that  the  Rontgen  rays  are  due  to  longi- 
tudinal vibrations,  that  would  constitute  such  a  very  great  difference  of 
nature  between  them  and  the  rays  of  light  that  a  very  great  difference  in 
properties  might  reasonably  be  expected.  But  assuming  that  the  Ront- 
geii  rays  are  a  process  which  goes  on  in  ether,  are  the  vibrations  belong- 
ing to  them  normal  or  transversal  ?  If  we  could  obtain  evidence  of  the 
polarization  of  those  rays,  that  would  prove  that  the  vibrations  were  not 
normal  but  transversal.  But  if  we  fail  to  obtain  evidence  of  polarization, 
that  does  not  at  once  prove  that  the  vibrations  may  not  after  all  be  trans- 
versal, because  the  properties  of  these  rays  are  such  as  to  lead  us  to 
expect  great  difficulties  in  the  way  of  putting  in  evidence  their  polariza- 
tion, if,  indeed,  they  are  capable  of  polarization  at  all.  Some  experi- 
mentalists have  attempted,  by  means  of  tourmalines,  to  obtain  evidence 
of  polarization,  but  the  result  in  general  has  been  negative.  Of  the  two 
photographic  markings  that  ought  to  be  of  unequal  intensity  on  the  sup- 
position of  polarization,  one  could  not  say  with  certainty  that  one  was 
darker  than  the  other.  Another  way  of  obtaining  polarized  light  is  by 
rellection  at  the  proper  angle  from  glass  or  other  substance ;  but,  unfor- 
tunately for  the  success  of  such  a  method,  the  Routgeu  rays  refuse  to  be 
regularly  reflected,  except  to  a  very  small  extent  indeed.  The  authors  of 
the  paper  to  which  I  have  already  referred  appear  to  have  had  some 
success  with  the  tourmaline.  Like  others  who  have  worked  at  the  same 
experiment,  they  took  a  tourmaline  cut  parallel  to  the  axis  and  put  on 


166  ELECTRO-THERAPEUTICS. 

lop  of  ii  two  others,  also  ciil  parallel  to  the  axis,  and  of  equal  thickness, 
which  were  placed  with  their  axis  parallel  an<l  perpendicular  respectively 
to  that  of  the  under  tourmaline. 

"But  they  supplemented  this  method  by  a  device  which  is  not 
explained  in  the  paper  itself,  although  a  memoir  is  referred  to  in  which 
the  explanation  is  to  be  found— at  least  of  those  who  can  read  the  Russian 
language,  which,  unfortunately,  I  cannot.  I  can,  therefore,  only  guess 
what  the  method  was.  It  is  something  depending  upon  the  superposition 
of  sensitive  photographic  films.  I  suspect  they  had  several  photographic 
films  superposed,  took  the  photographs  on  these,  and  then  took  them 
asunder  for  development,  and  after  development  put  them  together  again, 
as  they  had  been  originally.  They  consider  that  they  have  succeeded  in 
obtaining  evidence  of  a  certain  amount  of  polarization.  If  we  assume 
that  evidence  undoubted,  it  decides  the  question  at  once.  But  as  the 
experiment,  as  made  in  this  way,  is  rather  a  delicate  one,  it  is  important 
for  the  evidence  that  we  should  consider  well  what  we  may  call  the 
Becquerel  rays.  I  shall  say  merely  that  they  appear  to  be  intermediate 
in  their  properties  between  the  Routgeu  rays  and  rays  of  ordinary  light. 
The  Becquerel  rays  undoubtedly  admit  of  polarization,  and  the  evidence 
appeai-s  on  the  whole  pretty  conclusive  that  the  Routgen  rays,  like 
rays  of  ordinary  light,  are  due  to  transversal,  and  not  to  longitudinal 
vibrations. 

ult  remains  to  be  explained,  if  we  can  explain  it,  wherein  lies  the 
difference  between  the  nature  of  the  Routgeu  rays  and  the  rays  of  ordinary 
light  which  accounts  for  the  strange  and  remarkable  difference  in  the 
properties  of  the  two.  I  may  mention  that,  although  Cauchy  and  Neu- 
mann, and  some  others  who  have  written  on  the  dynamical  theory  of 
double  refraction,  have  been  led  to  the  contemplation  of  normal  vibrat  ions, 
Green  has  put  forward  what  seems  to  me  a  very  strong  argument  against 
the  existence  of  normal  vibrations  in  the  case  of  light.  The  argument 
Green  used  always  weighed  strongly  with  me  against  the  supposition  that 
the  Rontgen  rays  were  due  to  longitudinal  vibrations;  and  the  experi- 
ments by  which,  as  I  conceive,  the  possibility  of  their  polarization  has 
now  been  established  so  completely  in  the  same  direction,  showing  that 
they  are  due,  assuming  them  to  l>e  some  process  going  on  in  the  ether,  to 
a  transversal  disturbance  of  some  kind." 

Chemical  and  Pholoyraphic  Effects. — One  of  the  peculiar  properties 
possessed  by  the  X-rays  is  that  they  produce  a  chemical  action  upon  the 
haloids  of  silver,  but  have  very  little  activity  in  other  reactions.  Dixon1 
asserts  that  these  rays  affect  no  combination  between  CO  and  O2.  "With 
such  combinations  as  argentic  nitrate  in  alcohol  or  HgCl,  in  ammonium 
oxalate  solution,  the  influence  of  the  Rontgen  rays  is  extremely  feeble. 

•Trans.  Them.  Soc.,  1896. 


THE  EOXTGEX  BAYS  IN  DIAGNOSIS.  1  <  i  7 

The  following  law  has  been  formulated  by  Yandex  \\  er.1  The  action  of 
the  rays  011  a  sensitive  film  varies  inversely  as  the  distance  between  them, 
instead  of  inversely  as  the  square  of  the  distance. 

Phyxioloylral  Effects.  —  The  physiological  ;iction  of  the  X-rays  will  be 
dealt  with  at  length,  in  the  chapter  devoted  to  X-ray  therapy. 

Tfif-ories.  —  The  nature  and  origin  of  the  Routgen  rays  is  as  little 
understood  to-day  as  when  first  discovered.  Many  and  varying  theories 
have  been  propounded;  principal  among  these  may  be  cited  the  views 
put  forth  by  Routgeu,  Crookes.  J.  ,T.  Thomson,  Stokes,  etc. 

Below  are  tabulated  the  theories  advanced  by  scientists  regarding  the 
probable  nature  of  these  rays.: 


1.  Solid  particles.      {  ^^     Tesla' 

iSalviom,  Att.  d.  Perug.,  8,  1  and  2. 

2.  Ether  wind. 

3.  Ether  vortices.     Michelson,  Amer.  J.  Science,  p.  312. 

4.  Ether  waves  (actual  movement)  . 

5.  Electro-magnetic. 

Longitudinal.     Runtgen,  1895,  loc.  rit. 

Boltzmann,  J.  f.  Gasb.,  39,  p.  71. 

With  transverse  component.     Jaumann,  Wied.  Ann.,  57,  p.  147. 
Transverse,      (a)  Very  small.     Goldhammer. 
(b)  Short  trains.     G.  G.  Stokes. 
J.  J.  Thomson. 

6.  New  phenomenon. 

Visibility  of  the   Rontgen   Rays. 

Prof.  E.  Dorn3  asserts  most  positively  that  the  X-rays  are  visible, 
opinions  to  the  contrary  notwithstanding.  In  support  of  his  statement, 
he  says  that  when  the  back  of  the  anti-cathode  is  presented  to  the 
observer's  eye,  a  faint  fluorescence  is  visible  on  the  screen,  whereas, 
with  the  tube  iu  the  correct  position,  the  eye  accustomed  to  darkness 
could  not  detect  the  smallest  action,  although  the  appearance  of  light  was 
distinctly  seen,  both  before  and  later.  In  corroboratiou,  Rontgeu  himself 
held  an  absorbing  metal  plate,  containing  a  narrow  slit,  before  the  eye, 
when  he  observed  a  bright  line,  either  straight  or  curved  in  direction, 
depending  on  the  relative  positions  of  the  anode,  the  slit,  and  the  eye. 

Velocity  of  Propagation  of  the  X-rays. 

R.  Blondlot4  lias  studied  the  speed  of  propagation  of  X-rays,  by  the 
fact  that  a  discharge  passes  more  readily  across  a  spark-gap  when  under 

'Jour.  dePhys.,  1897. 

2  Hyndman  on  "  Radiation." 

3  Archives  of  the  Rontgen  Ray,  May,  1898,  p.  69. 

4  Coinptes-rendus,  Oct.  27  and  Nov.  3,  1902.     The  Electrician  (translation),  Nov. 
21,  1902. 


168  ELECTKO-T 1 1  K 1 1 APEUTICS. 

the  influence  of  the  rays  than  when  the  latter  are  not  present.  He  also 
demonstrated  that  the  X-rays  have  a  definite  rate  of  speed,  possessing  a 
velocity  comparable  to  the  Hertzian  waves.  Believing  that  the  rate  of 
propagation  of  the  latter  through  wire  is  equal  to  the  velocity  of  light, 
Bloudlot  asserts  that  the  velocity  of  X-rays,  Hertzian  waves,  and 
ordinary  light  waves  is  equal. 

Velocity  of  the  Rontgen  Rays. 

E.  Marx '  has  succeeded  in  measuring  the  velocity  of  the  X-rays,  by 
a  method  very  similar  to  that  of  Fizeau's  toothed  wheels,  as  used  for 
determining  the  velocity  of  light ;  but  in  Marx's  method  the  intermit- 
tence  is  inherent  in  the  source  and  the  receiver  themselves.  Rontgen 
rays  are  generated  by  Hertzian  waves,  and,  as  the  Rontgen  rays  are  the 
parent  rays  of  the  cathode  rays,  the  latter  are  only  emitted  during  the 
negative  phase  of  the  Hertzian  oscillation,  i.  e.  during  the  intermission. 
The  receiver  is  an  electrode,  connected  with  the  same  exciting  agent  and 
producing  secondary  cathode  rays,  under  the  influence  of  the  incident 
Routgen  rays,  but  only  when  found  by  them  in  the  negative  phase. 
Now,  as  the  X-rays  produce  peculiar  oscillations  in  the  leads,  Marx  has 
overcome  this  difficulty  by  employing  a  method  in  which  the  source 
and  receiver  are  both  fed  from  the  same  Hertzian  oscillating  wires, 
minimizing  infinitesiinally  the  oscillations  by  shifting  the  bridge. 

Charging  Action  of  the  Rontgen  Rays. 

That  the  X-rays  are  capable  of  charging  bodies  has  been  maintained 
by  Righi  but  denied  by  others.  Hahn's2  views  are  fully  in  accord  with 
those  of  Righi.  The  discord  that  exists  is  solely  due  to  the  masking 
action  of  the  secondary  rays.  All  bodies  acted  upon  by  the  X-rays 
acquire  a  positive  charge  ;  hard  rays  are  most  effective  in  charging,  as  is 
also  a  high  atomic  weight. 

1  Physikalische  Zeitechrift,  November  9,  1905. 
*Annalen  der  Phyeik,  No.  11,  1905. 


CHAPTER  I 
THE  ROXTGEN  RAY  APPARATUS  AND  ITS  MANIPULATION. 

I.  The  Induction  Coil. 

A.  LAWS  OF  FARADAY,  OR  THE  ELEMENTARY  LAWS  OF  INDUCTION. 

THE  induction  or  Ruhmkorff  coil  is  an  instrument  for  converting 
low  voltage  into  high  E.  M.  F.,  thus  necessarily  involving  the  principles 
of  electro- magnetic  induction. 

In  1831  Faraday  discovered  that  currents  may  be  induced  in  a  closed 
circuit  by  moving  magnets  near  it,  or  by  moving  the  circuit  across  the 
magnetic  field.  Further  investigation  showed  that  a  current  whose 
strength  is  changing  may  induce  a  secondary  current  in  a  closed  circuit 
near  it. 

In  1832  Faraday  observed  that  a  similar  induction  of  a  secondary 
current  occurred  when  interrupting  an  existing  primary  current,  and  the 
current  produced  in  the  secondary  circuit  on  interruption  travels  in  the 
same  direction  as  the  former.  When  closing  the  primary  circuit,  the 
secondary  current  travels  in  the  opposite  direction.  By  rapidly 
" making"  (closing)  and  " breaking"  (interrupting)  the  primary  cir- 
cuit, there  is  produced  an  alternating  current  in  the  secondary  circuit, 
which  is  constantly  changing  in  direction. 

The  current  strength  produced  by  induction  in  the  secondary  circuit 
is  dependent  upon  the  following  principles  : 

The  greater  the  ratio  in  the  induction  coil  between  the  primary  sec- 
tion and  the  secondary  coil,  the  greater  will  be  the  resulting  E.  M.  F.  of 
the  induced  current  in  the  secondary  circuit. 

By  induction,  the  greater  the  E.  M.  F.  in  the  primary  circuit,  the 
greater  the  increase  of  current  strength  in  the  secondary  circuit. 

The  strength  of  the  induced  current  will  vary  with  the  rapidity 
with  which  the  iron  core  is  alternately  magnetized  and  demagnetized. 

The  working  capacity  of  an  induction  coil  depends  upon  the  circum- 
stances that : 

The  core  must  be  of  soft  iron  that  can  readily  be  magnetized  or  de- 
magnetized by  an  interrupter  in  the  primary  circuit. 

The  secondary  circuit  must  consist  of  a  great  many  turns  of  fine 
wire,  so  as  not  to  increase  the  bulk. 

The  primary  coils  carry  the  current  from  battery,  accumulator,  or 
main,  which  magnetizes  the  core  of  soft  iron,  thus  creating  a  powerful 
magnetic  field  around  and  through  the  secondary  windings.  The  inter- 
rupter causes  the  current  in  the  primary  circuit  to  vary  rapidly,  and  the 

169 


170 


ELECTBO-THEBAPEUTICS. 


resulting  variations  in  the  intensity  of  the  magnetic  Held  react  upon  the 
secondary  coil,  inducing  an  electro-motive  force  in  each  and  every  turn  of 
the  wire.  The  "making"  of  the  magnetic  Held  is  much  more  slowly 
accomplished  than  its  destruction  when  the  current  is  "broken,"  thus, 
the  induced  electro-motive  force  in  the  secondary  at  "breaking"  is  l»y 
far  the  greater.  The  induced  secondary  current  when  "making"  is 
greatly  below  that  when  "breaking,"  so  that  the  former  is  found  insuffi- 
cient in  exciting  a  vacuum  tube.  Advantage  is  gained  from  this  phenom- 
enon because  the  induced  current 
at  "make"  travels  in  the  wrong 
direction  and  could  not  cause 
the  tube  to  be  excited,  as  it  is 
in  the  case  with  the  "  break" 
induced  current. 

The  induction  of  currents 
in  the  secondary  coil  by  means 
of  the  currents  in  the  primary 
coil  may  be  more  readily  under- 
stood from  a  consideration  of 
Fig.  68. 

The  battery  "B"  will  cause 
a  current  to  flow  through  the 
primary  coil  "P"  when  the  cir- 
cuit is  closed  by  the  interrupter 
"I;"  but  the  current  does  not 
instantly  assume  its  maximum 
value.  It  takes  an  appreciable 
time  to  rise  to  the  current  value 
set  by  the  resistance  of  the  cir- 
cuit. This  gradual  rise  of  the 
current  is  due  to  the  presence 
of  the  self  induction  of  the  cir- 
cuit, the  largest  percentage  of  which  exists  in  the  primary  coil.  During 
the  time  that  this  self-induction  current  is  rising  in  the  primary 
circuit,  a  magnetic  field  is  being  established  about  the  primary  wind- 
ing. The  strength  of  this  magnetic  field  is  at  all  times  directly  pro- 
portional to  the  primary  current.  It  is,  therefore,  zero  at  the  time  that 
no  current  flows,  and  a  maximum  when  the  current  has  stopped  rising. 
This  magnetic  field  embraces  the  secondary  coil  as  well  as  the  primary. 
While  the  primary  current  is  rising  and  the  magnetic  field  is  growing,  a 
voltage  is  produced  in  the  secondary  coil  by  the  expansive  lines  of  mag- 
netic force,  which  voltage  tends  to  produce  a  current  in  the  secondary 
coil  opposite  in  direction  to  that  flowing  in  the  primary. 


^HMHHHK 

B 

Flu.  68.— Diagram  illustrating  the  principles  of  in- 
duction.   (After  Dona th.) 


THE  BONTGKN   KAY  API'AR  ATI's.  171 

This  current,  induced  at  this  time,  is  of  low  voltage  and  is  not  the 
current  desired  in  the  X-ray  tube.  It  is  the  ••inverse"  discharge  which 
tends  to  blacken  tin-  tubes  and  lower  the  vacuum  at  the  time  of  the 
running  of  the  tube. 

AVheii  the  interrupter  opens  the  primary  circuit,  the  primary  cur- 
rent suddenly  stops,  and  at  the  same  time  the  magnetic  field  collap>r>. 
inducing  a  very  high  voltage  in  the  secondary  coil.  This  tends  to  pro- 
duce a  current  in  the  secondary  coil  iu  the  same  direction  as  the  current 
flowing  in  the  primary. 

B.  THE  CONSTRUCTION  OF  THE  INDUCTION  COIL. 

1.  The  Primtiri/  Coil. — The  first  requirement  in  the  construction  of 
an  X-ray  induction  coil  consists  in  arranging  into  a  cylindrical  bundle 
many  equal  lengths  of  finely  annealed  charcoal  iron  wire,  and  in  winding 
around  this   core,  several    layers   iu  thickness,  a  stout    insulated  (pri- 
mary) wire  so  arranged  as  to  have  terminals  at  one  end  for  future  con- 
nection.    Surrounding  this  cylinder  is  another   cylinder  made  of  some 
specially  selected  substance,  as  ebonite,  hard  rubber,  shellac,  or  resin,  to 
afford  insulation. 

2.  The  secondary  coil  is  composed  of  a  great  number  of  windings  of 
very  fine  wire,  to  effect  the  principle  that  a  high  E.  M.  F.  is  in  a  great 
degree  dependent  upon  the  number  of  turns  in  the  secondary  coil.     The 
secondary  coil  is  found  on  the  market  made  up  in  sections.     This  allows 
of  the  easy  replacement  of  any  one  section  ;  a  source  of  economy. 

The  ends  of  the  secondary  coil  are  connected  with  brass  terminals 
mounted  upon  the  flanges,  an  ebonite  cover  or  separate  stands.  The 
whole  finished  coil  is  suitably  supported  upon  a  stage  of  wood  with  the 
other  necessary  appliances. 

3.  Condenser. — The  purpose  of  the  condenser  is  for  the  sudden  and 
complete  demagnetization  of  the  soft  iron  core — the  length  of  the  spark 
depending    upon   the  abruptness  with   which  the   demagnetization   is 
accomplished.     Another  use  of  the  condenser  is  to  prevent  the  sparking 
of  the  extra  current  passing  between  the  contact  studs  of  the  interrupter. 
The  more  recent  condensers  are  .made  in  sections  and  are  provided  with 
an  indicating  dial,  designating  how  much  to  increase  or  decrease  the 
capacity  of  the  condenser,  as  determined  by  the  size  of  the  primary  coil. 
The  condenser  is  made   up   of  many  sheets   of  tin-foil  separated   from 
each  other  by  sheets  of  paraffin  paper,  or  paper  impregnated  with  resin 
or  plates  of  mica.    The  foil  is  arranged  thus  :    The  first,  third,  and  fifth 
sheets  are  so  connected  as  to  overlap  the  paper  sheets  on  one  side  :  the 
same  method  is  applied  to  the  union  of  the  even  numbered  sheets  of  the 
other  :  these  layers  are  connected  with  those  parts  of  the  interrupter 
where  the   "make"  and  ••  break"   occur.     The  unit  of  capacity  is  the 


172  ELECTRO-THERAPEUTICS. 

"micro-farad."  The  capacity  of  condensers  used  in  induction  coils 
varies  from  one-half  M.  F.  to  12  or  15  M.  F.,  depending  upon  the  size, 
make  of  the  coil,  and  the  voltage  upon  which  its  primary  circuit  is  used. 
The  commutator  is  an  appliance  mounted  on  the  base  for  the  support 
of  the  coil,  and  placed  at  the  side  of  the  interrupter.  It  is  a  double 
reversible  switch  capable  of  changing  the  direction  of  the  current  in  the 
primary  and  consequently  in  the  secondary  circuit. 

C.  INTERRUPTERS. 

The  interrupter  (rheotome)  is  a  device  employed  by  electricians  for 
the  purpose  of  effecting  rapidly  succeeding  induced  currents  in  the 
secondary  coil,  by  a  corresponding  rapidity  in  the  opening  ("break- 
ing") and  closing  (" making ")  of  the  primary  coil.  Interrupters  are 
divided  into  the  mechanical  and  the  electrolytic,  with  the  following 

subdivisions : 

1.  Mechanical. 

Platinum. 

Vibrating  hammer. 
Independent. 
Self- starting. 
Vril. 
Mercury. 
Dipper. 
Rotary. 

Disk. 

Johnston. 

Jet. 

2.  Electrolytic. 

Wehnelt. 

Caldwell  and  Simon. 

Platinum. — The  vibrating  hammer  which  vibrates  in  response  to  the 
magnetism  exerted  by  the  primary  coil  is  little  used  at  present. 

The  independent  vibrating  hammer  is  so  constructed  that  a  magnet 
placed  in  a  shunt  circuit  can  vibrate  the  hammer  independently  of  the 
coil.  The  diameter  of  the  contacts  should  be  as  large  as  possible,  and 
the  faces  absolutely  parallel,  in  order  to  carry  all  the  current  required. 
The  number  of  interruptions  in  this  hammer  is  dependent  upon  the 
number  of  weights  attached  to  the  vibrating  hammer.  The  greater  the 
number  of  weights  employed,  the  fewer  will  be  the  resulting  vibrations. 

The  self-starting  (Figs.  69,  70)  mechanical  interrupter  requires  little 
attention  from  the  operator,  as  he  is  not  called  upon  to  effect  the  vibra- 
tions. This  ingenious  invention  is  the  work  of  H.  C.  Snook  and  Edwin 
\V.  Kelly,  of  Philadelphia,  who  aptly  say  : 

"This  interrupter  is  a  form  of  platinum  break  which  is  actuated  not 
by  the  magnetic  field  of  the  coil  itself,  but  by  an  independent  electro- 


FIG.  69.— Self-starting  interrupter. 


FIG.  70.— Diagrammatic  sectional  view  of  the  self-starting  interrupter. 
(Rontgen  Manufacturing  Co.) 


THE  ROXTGEX  HAY  APPAHATI  S.          17:j 

magnet  (9),  which  is  in  series  with  a  small  spring  (11)  and  a  set  of  plati- 
num contacts  of  its  own.  and  is  shunted  directly  across  the  supply  wires. 

"The  magnetic  circuit  is  so  arranged  that  a  very  powerful  pull  is  ex- 
erted on  the  armature  at  the  instant  of  starting  from  rest.  This  provides 
the  self-starting  feature  which  has  given  to  the  interrupter  its  name. 
The  break  is  quite  efficient  and  gives  very  little  trouble. 

"This  has  been  accomplished  by  making  the  magnetic  circuit  with 
a  minimum  amount  of  reluctance,  and  providing  a  properly  shaped  anna 
ture  and  pole  piece.  The  magnetic  circuit  is  completed  from  the  arma- 
ture to  the  base  of  the  magnet  coil  through  the  interrupter  spring  itself. 
By  this  arrangement  the  only  air  gap  in  the  path  of  the  magnetic  lines  of 
force  is  that  between  the  pole  piece  and  the  armature  itself,  making  the 
tractive  force  exerted  on  the  armature  a  maximum  for  the  magnetizing 
current  employed." 

The  "vrtt"  interrupter  is  an  old  type  of  the  spring  platinum  vari- 
ety. It  is  rapidly  passing  into  disuse,  but  it  possesses  the  great  advan- 
tage of  being  capable  of  generating  a  high  E.  M.  F.  in  the  secondary 
coil.  Sparking  is  unavoidable,  and  its  occurrence  constantly  menaces  the 
integrity  of  the  platinum  stud. 

To  obviate  this  difficulty  the  elasticity  of  the  spring  is  no  longer  taken 
advantage  of,  but  in  its  place  a  light  piece  of  flat  metal,  balanced  on  its 
edge,  is  substituted  for  the  movable  contact. 


FIG.  71. — Mercury  interrupter. 

Mercury. — Mercury  interrupters  are  of  two  kinds — the  dipper  and  the 
rot < try.  In  the  dipper  variety  an  electro- motor  (Fig.  71)  is  employed  to 
effect  the  "dip,''  and  likewise  the  withdrawal  of  a  platinum-tipped  rod 
from  contact  with  the  mercury  for  the  greater  part  of  each  cycle;  it  is  out 
of  the  mercury  for  a  relatively  short  period,  because  the  current  is  not 


174  ELECTRO-THERAPEUTICS. 

generated  at  the  moment  of  contact.  In  this  form  of  interrupter  the  sur- 
face of  the  mercury  is  covered  with  a  layer  of  alcohol,  water,  or  petroleum. 
in  order  to  decrease  the  oxidation  resulting  from  ''sparking."  This  form 
of  " break"  is  cumbersome,  being  mounted  on  a  separate  base.  Instead 
of  being  worked  by  the  core  of  the  coil,  this  interrupter  may  be  brought 
into  action  by  employing  a  small  motor.  One  precaution,  however,  with 
the  latter  method  is  necessary.  If  the  breaks  are  not  started  prior  to  the 
turning  on  of  the  current  into  the  coil,  the  coil  may  suffer  serious  dam- 
age by  the  heavy  influx  of  current  upon  closing  the  circuit,  should  the 
dipper  be  immersed  in  the  mercury. 

Davidson-  s  Rotary  Contact  Breaker. — Dr.  Mackenzie  Davidson's  inter- 
rupter1 (Fig.  72)  consists  of  a  vane  mounted  at  the  end  of  a  spindle 
driven  by  a  small  motor.  As  the  latter  rotates,  the  vane  makes  and 
breaks  contact  with  the  mercury  contained  in  a  trough  or  box,  on  the 
cover  of  which  the  motor  is  mounted.  The  motor  and  spindle  are  placed 
at  an  angle  of  about  30°  so  that  the  spindle  passes  down  through  a  hole 
in  the  lid.  The  mercury  is  thus  closed  in,  and  splashing  is  prevented. 
The  break  is  found  to  work  well  with  electro-motive  force  up  to  100  volts. 

The  disk  interrupter,  a  subdivision  of  the  rotary,  is  included  in  that 
class  of  ll breaks"  in  which  the  contacts  are  separated  by  the  revolutions 
of  a  disk  effected  through  the  agency  of  an  electro-motor.  The  contacts 
and  disks  are  immersed  in  alcohol  or  petroleum,  to  prevent  the  likelihood 
of  sparking. 

The  Johnston  Mercury  Interrupter. — Dr.  Geo.  C.  Johnston,  of  Pitts- 
burg,  exhibited  before  the  American  Rontgen  Ray  Society  in  Baltimore, 
1905,  a  new  form  of  mercury  interrupter  (Fig.  73)  for  which  he  claims 
special  features.  There  is  no  oxidation  of  mercury,  no  sticking,  uniform- 
ity of  discharge,  absolute  control  of  speed  and  current,  it  will  not  ex- 
plode, it  occupies  little  space,  makes  little  noise,  and  will  run  for  months 
with  little  attention.  He  describes  the  Johnston  mercury  interrupter  as 
follows :  u  The  interrupter  consists  of  an  inclined  shaft  at  the  lower  end  of 
which  is  a  peculiar  shaped  blade,  alternately  dipping  into  a  pool  of  mer- 
cury. This  shaft  is  rotated  by  means  of  a  motor  to  which  a  speed  con- 
trol is  attached.  The  containing  case  is  of  heavy  cast  iron,  and  the  top  is 
screwed  down  and  insulated  from  the  case  with  a  thick  rubber  gasket  and 
insulated  bushings.  One  end  of  the  box  is  inclined  toward  the  mercury 
pool  and  arranged  with  grooves,  so  that  when  the  mercury  is  thrown  to 
the  top  of  this  incline  by  the  action  of  the  blade,  in  running  back  into  the 
pool,  it  travels  slowly  over  a  considerable  section  of  the  cast  iron  and 
leaves  any  impurities  that  it  might  have  contained  in  them. 

"The  box  is  arranged  to  be  air-tight,  and  the  pet  cock  is  fastened 
in  the  lid,  by  means  of  which  the  mercury  or  any  other  liquid  can  be 

'Archives  of  the  Rontgen  Ray,  Jan.,  11K)1. 


FIG.  72.— Davidson's  interrupter. 


JOHNSTON  t*£ACUffY  INTERRUPTER 

PAT. APPLIED   FOR 
MAO£   r 

UEEN  ft 

SOLE  LI 


Fi(i.  73.— Johnston's  mercury  interrupter. 


THE  RONTGKN    KAY  APPARATTS. 


175 


poured  into  the  interior.  It  has  been  found  that  when  the  proper  amount 
of  mercury  is  placed  in  the  pool  and  a  few  drops  of  wood  alcohol  added, 
after  the  first  slight  explosion  takes  place,  the  interrupter  will  run  along 
without  any  sparking,  and  consequent  oxidation  of  the  mercury,  and 
break  currents  of  considerable  magnitude,  as  much  as  40  or  50  amperes. 
The  quality  of  the  spark  obtained  from  the  secondary  of  an  induction 
coil  with  this  amount  of  current  flowing  through  its  primary,  is  surpris- 
ingly thick  and  heavy,  and  the  discharge  is  of  exactly  the  right  quality 
to  produce  the  results  in  radiography.  When  the  alcohol  explodes  in 
the  box,  there  is  a  slight  pressure  produced,  which  is  retained,  owing  to 
the  air-tight  quality  of  the  box,  and  the  interrupter  will  run  along  indefi- 
nitely with  absolutely  no  attention.  If  any  irregularity  of  the  secondary 
sparking  is  noticed,  all  that 
is  necessary  to  do  is  to  open 
the  pet  cock,  pour  in  an  ounce 
or  so  of  mercury  and  a  dozen 
or  fifteen  drops  of  wood  alco- 
hol, close  the  pet  cock,  and 
the  interrupter  is  ready  for 
n>e  again.  This  interrupter 
will  run  for  a  long  time  with- 
out interior  cleaning,  which 


FIG.  74.— Wehnelt  interrupter. 


can  be  readily  accomplished 
without  taking  apart,  by  un- 
screwing a  plug  in  the  bottom 
of  the  box,  letting  the  mer- 
cury drain  out,  and  filling  the  u 
l)o x  with  water  and  giving  it 
i\\o  or  three  vigorous  shak- 
ings. After  draining  the 
water  out,  the  plug  is  re- 
placed tightly,  and  some  fre^h 
mercury  added,  when  it  is  ready  for  another  three  or  four  months'  use." 

In  the  jet  interrupter,  a  jet  of  mercury  impinges  upon  a  rotating 
metallic  surface.  The  jet  carries  the  current,  and  the  length  of  contact 
can  be  regulated  according  to  the  operator's  demands  by  elevating  or  low- 
ering the  contact  plate  relatively  to  the  jet.  The  break  is  instantaneous 
and  complete. 

The  electrolytic  iitfcrrii.jrfrrs  are  subdivided  as  follows  :  Wehnelt  and 
the  CahhceU  and  Simon. 

This  type  of  interrupter  depends  upon  the  formation  of  gas  bubbles 
at  the  poles  of  an  electrolytic  cell. 

Tin-  i-h'ctrolytic  "break"  of  Wfhuclt  (Fig.   74),  the  most  rapid  of  all 


176 


ELECTRO-THERAPEUTICS. 


interrupters,  consists  of  a  jar  holding  the  electrolyte  (dilute  sulphuric 
acid  s.  g.  1016  to  1020),  a  plate  of  lead  (the  cathode),  and  a  piece  of 
platinum  insulated  except  at  its  extremity  (the  anode).1 

The  greater  the  quantity  of  sulphuric  acid  employed,  the  greater  the 
current  and  the  better  the  conductor.  A  steady  electro-motive  force  of  at 
least  24  volts  is  applied  to  the  interrupter,  arranged  in  series  with  the 
primary  circuit  of  the  coil.  Should  the  platinum  not  constitute  the 
anode,  the  interruptions  will  not  be  sharp  and  regular.  Under  these  con- 
ditions the  platinum  is  very  rapidly  consumed. 

One  of  the  advantages  of  this  interrupter  is  that  either  a  continuous 
or  alternating  current  can  be  employed.  It  likewise  obviates  the  use  of 

the  condenser,  and  in  many 
instances  the  rheostat.  An- 
other advantage  is,  that  it 
allows  tremendous  amounts  of 
amperage  to  pass  to  the  pri- 
mary coil,  averaging  any 
where  from  fifteen  to  fort}' 
amperes. 

The  number  of  interrup- 
tions in  this  break  varies  from 
1000  to  40,000  per  minute, 
and  is  dependent  upon  the 
size  of  the  exposed  portion  of 
the  platinum  point.  This  can 
be  regulated  by  presenting  a 
larger  surface  either  by  means 
of  a  screwing  device,  or  by 
>  several  thicknesses  of  these 
points  in  the  same  electrolyte. 
The  rate  of  interruption  can 
be  gauged  by  the  tuning- 
fork  5  or  as  the  result  of  ex- 
perience, the  operator  recognizing  a  peculiar  humming,  musical  note. 
A  recent  device,  added  to  this  instrument,  is  a  spiral  leaden  tube, 
which  acts  as  the  cathode,  and  as  the  sulphuric  acid  (electrolyte)  becomes 
warm  the  interruptions  cease  to  be  regular,  and  water  from  a  faucet  is 
passed  through  the  tubing  in  order  to  cool  the  electrolyte. 

In  the  film  variety  of  the  Wehnelt  interrupter,  the  interruptions  are 
brought  about  by  the  production  of  a  non-conducting  film  of  vaporor  gas 
around  the  anode.  The  effects  produced  are.  in  a  measure,  proportionate 


FIG.  75.— Simon  interrupter. 


'In  1S!H)  \\Vlmelt,  of  Charlottenburg,  first  applied  the  above  principles  to  the 
satisfactory  working  of  ihe  X-ray  coil. 


THE  ROXTGEN  RAY  APPARATUS. 


177 


to  the  thickness  of  the  wire,  so  that  the  employment  of  three  or  more  wires 
of  different  gauges  is  often  expedient.  Most  advantage  is  gained  with  an 
E.  M.  F.  of  50  to  120  volts.  The  voltage  is  regulated  by  ineaus  of  a  rheo- 
stat. For  short  runs  a  voltage  of  40  to  100  volts  is  all  that  is  required, 
but  its  employment  must  be  for  a  brief  interval  only.  To  continue  for  a 
half  hour  or  au  hour  would  cause  the  geueratiou  of  great  heat  ill  the  acid, 


FIG.  76.— Friedlander  electrolytic  interrupter.  The  electrolyte  is  composed  of  a  10  per  cent,  solu- 
tion of  magnesium  sulphate,  and  the  anode  is  made  of  German-silver  wire.  The  operator  can  control 
the  current  for  the  work  in  hand  by  simply  turning  the  thumb-screw.  It  operates  by  either  the  direct 
or  alternating  currents. 

with  a  stoppage  of  the  mechanism.  To  avoid  this  drawback,  many  devices 
have  been  employed.  Among  the  most  important  are  the  use  of  the  sul- 
phates of  magnesia  and  potash -alum  in  place  of  the  acidulated  solution, 
and  also  by  making  the  container  larger,  and  through  it  maintaining  a  flow 
of  cold  water.  This  type  of  interrupter  is  easily  managed;  its  most  pro- 
nounced disadvantage  is  its  constant  humming  sound,  while  its  very  high 
E.  M.  F.  has  a  tendency  to  disturb  the  vacuum  of  the  Crookes  tube. 


178  ,     ELECTRO-THERAPEUTICS. 

There  are  very  many  varieties  of  the  electrolytic  interrupter, 
numerous  modifications  of  the  Wehuelt,  bearing  various  names. 

Caldicrfl  and  Simon.— In  1899  Mr.  E.  \V.  Caldwell,  of  Xew  York,  and 
Dr.  H.  T.  Simon,  of  Berlin,  simultaneously  and  independently  of  each 
other,  had  published  the  description  of  a  new  type  of  electrolytic  inter- 
rupter, the  principle  involved  being  the  production  of  interruptions  by 
the  vaporization  of  the  electrolyte  at  the  aperture  connecting  the  two 
chambers.  The  apparatus  consists  of  a  glass  jar  containing  dilute  sulphu- 
ric acid,  with  two  plates  of  lead,  one  for  the  anode  and  the  other  for  the 
cathode.  A  partition  of  glass  or  porcelain,  containing  a  hole,  separates 
these  two  plates  and  at  the  same  time  allows  the  communication  of 
the  liquids  in  the  two  portions  of  the  cell.  The  frequency  of  the  inter 
ruptions  is  dependent  upon  the  strength  of  the  current,  the  size  of  the 
aperture,  the  resistance  offered  by  the  electrolyte,  and  to  some  extent 
upon  the  inductance  of  the  circuit.  A  pointed  rod,  non-conducting  in 
nature,  regulates  the  number  of  interruptions  by  increasing  or  decreas- 
ing the  calibre  of  the  aperture.  The  electrolytic  action  results  in  the 
generation  of  bubbles  of  gas  (steam),  which  break  the  circuit ;  these 
bubbles  are  almost  instantaneously  dissipated  and  then  renewed,  their 
frequency  being  somewhat  dependent  upon  the  size  of  the  aperture. 
More  recently  the  septum  between  the  two  containers  has  been  made  of 
perforated  porcelain  disks,  in  order  to  prevent  the  damage  incident  to 
the  inner  tube,  from  the  unequal  expansion  of  the  glass  of  which  it  was 
formerly  made. 

Dr.  Simon  claims  that  the  advantage  of  his  interrupter  (Fig.  75) 
over  the  Wehnelt  is  to  be  found  in  its  being  independent  of  the  current 
direction,  working  equally  as  well  with  the  alternating  as  with  the  contin- 
uous current ;  because  in  the  Caldwell-Simon  interrupter,  the  wat'-rv 
vapor  is  periodically  evolved  and  followed  each  time  by  condensation, 
and  thus  the  current  is  alternately  made  and  broken. 

A  useful  electrolytic  interrupter  is  shown  in  Fig.  76. 

D.  VARIETIES  OF  INDUCTION  COIL. 

(a)  Variable  Pi-iinani  T  ml  net  ion  A///.S. — Walter,  of  Hamburg,  con- 
structed induction  coils  with  a  variable  number  of  sections  for  the  pri- 
mary, in  order  to  obtain  the  proper  quality  in  the  secondary  discharge. 
This  he  effected  by  arranging  the  windings  of  the  primary  coil  in  a  num- 
ber of  sections,  and  passing  the  current  through  a  greater  or  lesser  number 
of  these  divisions  us  he  required  more  or  less  current.  Each  of  the  coil 
windings  can  be  connected  in  series,  in  two  groups,  or  in  parallel.  These 
windings  end  in  wires  to  form  eontaets  at  one  side  of  the  primary  coil. 
Upon  these  contacts  a i  ••  plaeed  pins  which  support  plugs,  and  so  arranged 
as  to  effect  the  desired  connection  between  the  terminals  of  the  coil 


THE  RONTGEN    RAY   APPARATUS.  179 

endings.  By  connect  ing  the  windings  in  series  (for  soft  tubes),  the  self 
induction  of  the  primary  coil  is  much  augmented.  By  conned  ing  in 
parallel  (for  hard  tubes),  or  in  two  groups  (for  tubes  of  medium  density), 
self  induction  is  materially  decreased. 

The  primary  coil  is  covered  with  an  insulator  of  glass,  ebonite,  par- 
affin, etc.  This  coil  is  frequently  manufactured  in  a  varying  number 
of  sections  or  divisions,  so  that  it  can  be  replaced  at  pleasure  within 
the  secondary  coil,  and  be  renewed,  at  any  time,  thus  obviating  the 
unnecessary  expense  of  providing  for  the  cost  of  the  entire  coil. 

The  secondary  circuit  must  be  perfectly  insulated  ;  lack  of  this  most 
important  provision  will  result  in  discharges  within  the  apparatus,  fusing 
the  wire  and  destroying  the  coil.  The  insulating  material  used  may  be 
paraffin,  varnish,  wax,  or  silk.  Whatever  substance  be  used,  the  several 
layers  of  wires  which  are  already  of  themselves  well  insulated  must  be 
likewise  insulated  from  one  another. 

A  wise  expedient  in  this  connection  has  been  the  device  of  employ- 
ing several  short  secondary  coils  in  place  of  a  single  secondary  coil.  This 
artifice  insures  better  insulation,  easy  repair  in  the  event  of  short- 
circuiting,  and  the  lessened  cost  incident  to  replacement. 

Tfir  Jumbo  Coil. — This  coil,  owing  to  its  mechanical  arrangement,  does 
not  throw  more  than  a  !)-inch  spark  (23cm.),  thus  making  it  necessary  to 
insulate  only  for  the  voltage  equivalent  for  that  spark  length.  This  saxes 
much  valuable  space,  and  it  is  therefore  possible  to  use  more  iron  in  the 
primary  core,  as  well  as  heavier  wire  on  both  primary  and  secondary, 
which  are  also  brought  into  closer  proximity  to  each  other.  In  this  way 
the  efficiency  is  so  increased  that  when  running  on  110  volts  direct  current, 
it  will  push  50  per  cent,  more  energy  through  a  tube  backing  up  three 
to  four  inches  parallel  spark-gap  than  any  standard  20-inch  (50-cm. ) 
coil.  (See  Fig.  101.) 

By  means  of  the  variable  inductance  of  the  primary,  the  value  of 
which  is  changed  by  moving  a  switch,  it  is  easy  to  adjust  the  voltage 
delivered  by  the  coil  to  suit  the  resistance  of  the  tube  being  used,  so  as  to 
force  the  greatest  amount  of  X-ray  producing  energy  through  it. 

The  switch  -board  is  provided  with  a  voltmeter  and  ammeter,  a 
switch  for  making  connection  for  use  of  either  the  mechanical  or  electro- 
lytic  interrupter,  a  condenser-switch  used  in  connection  with  the  mechan- 
ical interrupter,  a  reversing-switch  to  change  the  polarity  of  the  dis- 
charge, and  a  regulating  rheostat. 

The  usual  method  of  operation  is  to  connect  the  tube  to  the  coil,  set 
the  inductance  switch  at  point  number  6,  maximum  inductance,  connect 
the  interrupter  desired,  close  the  reversing-switch  so  as  to  allow  the 
current  to  pass  into  the  primary,  and  adjust  the  current  by  means  of  the 
regulating  rheostat. 


180 


ELECTKO-T 1 1 K  RAT K I  'TICS. 


If  the  tube  does  not  light  up  properly,  the  current  is  tin-own  off,  the 
inductance  switch  changed,  and  the  tube  excited  again.  This  adjustment 
is  very  simple,  and  the  proper  inductance  for  any  tube  for  skiagraphy  or 
for  X-ray  therapy  is  readily  obtained. 

(b)  Tesla  Coil. — The  Tesla  coil  became  universally  known  when 
Routgeu's  discovery  was  first  verified  throughout  the  civilized  world. 
The  alternating  currents  resulting  from,  the  action  of  this  device  are  of 
exceedingly  high  frequency  (10  to  20  millions  per  second)  as  compared 
with  the  Ruhmkorff  coil  with  mechanical  contact  breakers ;  whilst  the 
induced  secondary  electro-motive  force  of  the  Tesla  coil  is  hundreds  of 
thousands  of  volts.  Comparable  to  the  rapidity  of  oscillations  thus  pro- 
duced, is  the  discharge  of  a  condenser  or  Ley  den  jar.  These  discharge 


V 


FIG.  77.— The  Tesla  oscillator. 


FIG.  78.— Outer  view  of  the  same. 


Currents  are  made  to  pass  through  the  primary  of  an  induction  coil,  devoid 
of  the  usual  iron  core.  The  primary  is  made  up  of  a  very  few  turns  of 
thick  wire ;  the  secondary  has  comparatively  only  a  few  turns  of  Mrire. 

So  great  is  the  electro-motive  force  that  the  average  non-conductor 
would  fail  to  effect  insulation  ;  hence  the  necessity  of  immersing  the  whole 
coil  in  an  oil  bath  from  which  only  the  primary  and  secondary  wires 
protrude. 

For  charging  the  condenser,  it  becomes  necessary  to  pass  the  alter- 
nating current  through  a  transformer,  which  raises  its  pressure  to  about 
6000  volts.  The  existence  of  a  bright,  snappy  spark,  in  the  adjustable 
spark-gap,  indicates  the  discharge  of  the  condenser. 

The  employment  of  the  Leyden  jar  is  fraught  with  much  danger,  if 
care  is  not  taken  to  make  the  primary  circuit  inaccessible.  On  the  other 
hand.  sparks  taken  from  the  secondary  of  a  Tesla  coil  are  innocuous;  but 
the  intense  and  continuous  crackling  produced  by  the  primary  spark-gap 
is  frequently  terrifying  to  nervous  patients  and  children. 

Tesla  Oscillator.  (Figs.  77,  78.)— This  device  consists  of  three  parts  : 
A  vertical  electro- magnet,  well  wound  very  many  times  with  stout  wire, 


THE  KOXT(Ji:X    KAY  APPARATUS.  181 

possessing  much  self-induction.  A  condenser,  which  is  charged  by  the 
sell'  induction  of  the  electro-magnet  on  breaking  the  circuit  which  dis- 
charges into  the  primary  of  the  horizontal  transformer.  The  latter  is 
composed  of  a  single  turn  of  copper  ribbon,  about  six  inches  wide,  and 
its  secondary  consists  of  one  layer  of  thick  wire. 

The  working  of  the  oscillator  is  as  follows  :  The  current  from  the 
terminal,  T2,  magnetizes  the  electro-magnet,  M,  which,  in  attracting  its 
armature,  breaks  the  circuit  at  B,  and  the  high  electro-motive  force,  due 
to  the  magnet's  self-induction,  charges  the  condenser  C.  The  discharge 
being  extremely  rapid  and  oscillatory  and  flowing  through  the  primary, 
P.  has  its  voltage  increased  in  the  secondary,  S.  The  rate  of  vibration 
should  be  tuned  below  one  hundred  per  second.  The  oscillator  is,  for 
some  unknown  reason,  not  put  upon  the  market.  In  the  laboratory  it  is 
found  to  be  inexpensive,  compact,  and  very  durable ;  the  absence  of  any 
delicate  wire  and  the  general  construction  of  the  device  aiford  almost 
indefinite  immunity  against  any  disturbance  of  its  insulation ;  but  for 
skiagraphic  work,  special  tubes  are  demanded,  because  of  the  alternating 
current  generated  by  the  oscillator. 

(c)  Kinraide  Coil. — The  Kinraide  coil,  the  ingenious  invention  of 
Mr.  T.  B.  Kiuraide,  of  Boston,  is  a  special  modification  of  the  Tesla  coil 
and  possesses  many  features  of  merit.1  Among  other  things  Mr.  Kin- 
raide remarks  :  "The  coil  I  have  succeeded  in  making  was  the  result  of 
the  repeated  breaking  down  of  the  Ruhmkorff  coils,  ranging  from  six 
to  eighteen  or  twenty  inches.  I  have  succeeded  very  well  in  removing^ 
from  the  apparatus  the  danger  of  destruction  so  common  to  the  ordinary 
Ruhmkorflf  coils,  etc.  My  object  was  to  remove  the  high -potential 
region  of  the  coil  as  far  as  possible  from  the  primary.  In  my  coil  this 
has  been  done,  the  low  potential  region  of  the  single  coil  being  the  only 
part  it  could  come  in  contact  with  *  *  *  *  the  moment  the  current 
is  broken,  the  lines  of  force  collapse  and  fall  inward  in  the  direction  of 
the  arrows.  (Fig.  79.)  In  this  way  the  highest  potential  is  produced 
in  the  outer  terminal  of  a  thin  flat  spiral  secondary,  if  located  in  the 
plane  of  the  arrows,  and  the  low  potential  at  the  centre.  By  that  method 
of  winding,  as  the  turns  grow  longer,  the  resistance  per  turn  increases, 
and  the  tendency  of  the  discharge  to  pass  from  one  turn  to  the  other  in- 
creases. If  a  suitable  primary  were  placed  on  the  outside  of  this  second- 
ar\ .  the  reverse  would  be  the  case,  and  hence  the  tendency  to  break  down 
would  be  entirely  removed  in  the  section  of  the  secondary.  In  my  coil 
this  is  the  arrangement  adopted,  and  the  lines  of  force  fall  away  from  the 
centre  towards  the  primary  in  the  direction  of  the  arrows  in  Fig.  80,  pro- 
ducing a  very  high  potential  at  the  centre,  and  practically  very  little  or 

1  American  Electro-Therapeutic  Association,  held  at  Buffalo,  New  York,  Septem- 
ber 24-26,  1901. 


182 


ELECTRO-TH  ER  APEUT I  ( \S. 


no  potential  at  the  outer  turns,  so  that  the  centre  discharges  in  (he 
proportion  of  about  six  inches  towards  the  earth  wire  whilst  the  outer 
terminal  discharges  about  three-fourths  of  an  inch  only.  To  remove  all 
tendency  of  discharge  towards  the  primary,  two  of  these  coils  were  placed 


FIG.  79.— Lines  of  force  fall  in  the  arrows  in  the  older  form  of  coil. 

side  by  side  (see  Fig.  81).  The  two  primaries  are  so  arranged  that  a 
high-potential  positive  and  negative  is  obtained  from  the  centre  terminals 
of  the  secondaries.  There  is  practically  no  tendency  whatever  in  this 
form  of  coil  to  break  down." 


Fio.  80.— Shows  the  arrangement  by  which  the  lines  of  force  fall  away  from  the 
centre  towards  the  primary,  as  indicated  by  the  arrows. 

In  order  to  present  in  a  clear  and  terse  manner  the  peculiarities  and 
advantages  possessed  by  this  recent  invention,  it  is  thought  wise  to 
append  tin-  following  abridged  description. 

The  coil  consists  of  two  separate  secondaries  with  their  primaries 
connected  in  series.  Each  secondary  has  a  high  ami  low- potential 


Till-:  RONTGEN   RAY    AIM 'A  II A  'ITS. 


183 


terminal,  due  to  the  position  and  the  method  of  winding  the  primary. 
The  primary  is  located  outside  the  secondary  winding.  The  secondaries 
arc  wound  in  single  flat  disks  and  lie  in  the  same  plane  as  the  primaries; 
with  this  method  of  construction  the  discharge  from  the  two  terminals  is 
vastly  different.  The  potential  at  the  central  terminal  of  the  secondary 
is  extremely  high,  while  that  of  the  outer  turns  near  the  primary  is  very 
low.  By  connecting  the  outer  terminals  of  two  such  secondaries  in  series, 
the  potential  of  the  outer  turns  entirely  disappears,  hence  there  is  no 
tendency  to  discharge  into  the  primary. 

There  is  absolutely  no  heating  in  the  primary  of  the  Kinraide  coil, 
as  is  the  case  with  the  Ruhmkorff,  so  that  the  insulation  cannot  be 
melted,  nor  is  there  heat  generated  where  it  can  in  any  way  affect  this 
delicate  part  of  the  apparatus. 

A  valuable  feature  is  the  water-cooled  spark-gap.  The  heat  ordina- 
rily developed  in  various  parts  of  other  coils  is  localized  here,  where  it 
can  be  cared  for  without  trouble  or  risk.  In  other  coils  there  is  a  single 


FIG.  81. — Shows  the  arrangement  of  two  coils  side  by  side  :  A,  A,  secondary ;  B,  B,  primary. 

discharge  from  every  interruption  of  the  primary  circuit.  "With  this 
spark-gap  we  have  a  high-frequency  apparatus  giving  many  hundred  dis- 
charges, or  surgings,  in  the  secondary  for  every  break  or  reversal  in 
the  primary.  This  diminishes  the  time  of  exposure  and  increases  the 
steadiness  of  the  illumination  of  the  screen. 

The  interrupter  is  solid  and  durable,  and  with  the  spark-gap 
embodies  an  entirely  new  principle,  running  at  constant  speed  till  the 
motor  is  stopped.  The  alternating  coil  requires  uo  interrupter,  but  the 
spark-gap  is  essential.  The  use  of  so  little  wire  in  the  coil  makes  the 
apparatus  compact,  strong,  and  portable.  The  current  consumed  is  about 
two  hundred  watts.  It  may  be  attached  to  any  incandescent  lamp  socket, 
either  direct  or  alternating  current. 


184  ELECTRO-THERAPEUTICS. 

(d)  Trtiitxformrr  icith   Closed  Magnetic  Circuit,    for  X-rays  and  H'ujh- 
rrx/Hi'iici/  ('iirnnfx. — Belot,  iu  his  admirable  work  on  Radiotherapy,  thus 
describes  the  above  apparatus  by  Gaiffe  &  Co.,  of  Paris: 

"This  new  apparatus  makes  it  possible  to  utilize  an  ordinary  alter- 
nating current,  without  au  interrupter,  either  for  the  production  of 
X-rays  or  for  high-frequency  currents.  It  consists  of  an  ordinary  trans- 
former, with  a  closed  magnetic  circuit,  receiving  an  alternating  current 
of  110  volts,  which  it  converts  into  one  of  60,000  volts. 

"The  current  should  pass  in  one  direction  only.  As  the  alternating 
current  produced  by  this  transformer  changes  its  polarity  with  each 
oscillation,  one  series  of  waves  must  be  absorbed  before  reaching  the 
tube.  For  this  purpose  two  Villard  valves  are  inserted  in  parallel  with 
the  tube  in  a  manner  indicated  by  Villard  himself. 

"A  commutator  converts  the  continuous  into  an  alternating  current. 
This  installation  is  equally  adapted  for  high-frequency  work.  It  is  only 
necessary  to  remove  the  Villard  valves  and  insert  the  spark-gap  in  order 
to  adjust  it  for  this  purpose." 

I  have  seen  Drs.  B6clere  in  the  St.  Autoine  and  Chas.  Infroit  in  the 
Salpetriere  Hospitals  employing  this  apparatus  with  satisfactory  results. 

(e)  Coil   without  Interrupter. — Max  Levy  read  a  paper  before  the 
Rontgeu  Congress  in  Berlin  on  a  new  form  of  apparatus  in  which  a  high- 
tension   alternating  current  is  utilized  without  the  interposition  of  any 
interrupter  or  condenser.     The  current  is  made  unidirectional  by  means 
of  a  " strom -spalter,"  or  current-sifter, — i.  e.,  a  pair  of  spark-gaps,  by 
means  of  which  one  phase  of  the  alternating  current  is  conducted  to  t  he 
earth  while  the  other  is  used  for  driving  the  focus-tube.     The  author 
expressed  the  opinion  that  within  the  next  few  years  we  shall  see  the 
total  abolition  of  interrupters  for  high-tension  currents.      I  have  seen 
the  Crookes  tube  well  lighted  up  in  his  laboratory  in  Berlin. 

Transformers. — Koch  and  Sterzel,  of  Dresden,  exhibited  before  the 
Berlin  Rontgen  Congress,  a  transformer,  by  means  of  which  a  constant 
current  is  transformed  into  an  alternating  current  through  the  agency  of 
a  dynamo,  which  drives  the  secondary  current- rectifier  on  the  same 
spindle,  thus  insuring  synchronism.  A  step-up  transformer  with  closed 
magnetic  circuit  is  used. 

The  Grisson  Resonator. l — This  is  a  device  for  dispensing  with  the  use 
of  an  interrupter,  and  thus  doing  away  with  the  "make"  current,  which 
is  so  destructive  to  the  focus- tubes.  A  condenser  of  large  capacity  is 
fitted  with  a  commutator,  and  so  arranged  that  it  is  charged  alternately 
to  a  positive  and  negative  potential.  This  is  connected  to  the  primary 
of  an  induction  coil,  whose  self-induction  is  so  adjusted  to  the  capacity  of 
the  condenser  that  resonance  is  obtained.  When  this  is  connected  to  a 

1  Archives  of  the  Rontgen  Ray,  April,  1906,  p.  308. 


THE  BONTGEN  RAY  APPARATUS.         185 

source  of  constant  current,  unidirectional  impulses  pass  through  the  pri- 
mary, and  these  are  transformed  in  the  secondary  to  the  necessary  tension 
required  for  working  the  focus-tube. 

Since  at  the  end  of  each  discharge  the  potential  of  the  condenser  falls 
to  zero,  there  will  be  no  spark  when  the  commutator  is  reversed.  We 
are  therefore  able  to  use  a  simple  mechanical  commutator,  consisting  of 
a  massive  copper  collector,  with  two  rotating  rings  connecting  its  plates. 
The  current  is  conducted  to  these  rings  by  means  of  contact  brushes. 
This  commutator  is  rapidly  rotated  by  an  electro- motor.  The  primary  of 
the  induction  coil  is  introduced  between  the  electric  source  and  this  com- 
mutator. When  the  circuit  is  first  closed  there  is  a  sudden  rush  of  elec- 
tricity through  the  coil,  the  current  instantaneously  attaining  a  maximum 
value.  As  the  condenser  becomes  charged,  the  intensity  of  the  current 
gradually  decreases  to  zero.  When  this  has  occurred  the  commutator 
will  break  the  circuit  without  any  sparking  (since  there  is  no  current). 
As  the  commutator  makes  contact  again  with  the  opposite  plate  of  the 
condenser,  there  will  be  another  sudden  rise  to  the  maximum  current, 
followed  by  a  gradual  fall  to  zero,  as  this  plate  now  becomes  charged  to 
the  potential  of  the  source.  The  contact  is  again  broken  after  the  cur- 
rent has  fallen  to  zero.  The  primary  of  the  induction  coil  is  thus  trav- 
ersed by  a  series  of  undirectional  impulses,  each  of  which  rapidly  attains 
a  maximum  value,  and  then  very  gradually  falls  to  zero — the  ideal  form 
of  current  for  obtaining  a  practically  unidirectional  current  in  the  sec- 
ondary. A  point  of  interest  is  that  it  is  the  "make"  current  which  is 
utilized  in  this  apparatus,  whilst  the  "break"  is  suppressed;  whereas 
in  the  ordinary  coil  our  efforts  have  been  directed  to  suppressing  the 
"make,"  and  utilizing  the  "break"  current. 

II.  Electrical    Discharges    in    Partial   Vacua    and    the    Crookes 
Vacuum  Tube. 

Before  taking  up  a  consideration  of  the  Crookes  vacuum  tube,  it  is 
Avell  to  observe  that  in  a  low-vacuum  tube  (Fig.  82)  there  is  a  column  of 
luminescence  at  the  positive  pole  and  extending  toward  the  cathode 
which  is  separated  by  a  dark  space  (an  interval  in  the  illustration)  desig- 
nated 1he  dark  space  of  Faraday.  In  Fig.  83  the  magnet,  AB,  shows 
the  deflection  of  the  rays.  As  the  pressure  decreases,  the  luminosity  in- 
creases in  volume,  and  as  the  pressure  becomes  still  smaller,  the  lumin- 
osity entirely  disappears;  on  the  other  hand,  as  the  vacuum  increases, 
there  is  a  marked  production  of  the  cathode  rays  as  shown  in  Fig.  84. 
The  deflection  of  the  cathode  rays  is  represented  in  Fig.  85.  In  Fig.  86, 
the  employment  of  one  coneave  i-athode  in  the  presence  of  a  number  of 
a  mules  is  shown.  As  the  vacuum  is  gradually  increased,  the  base  of  the 
cathodie  cone  becomes  successively  narrower  as  depicted  in  2  and  3. 


186 


ELECTBO-THEKAPEUTICS. 


y  ' 


B 


FIGS.  82,  83.— Discharge  passing  through  low-vacuum  tubes.    (Bouchard. ) 


FIG.  84.— Cathode  rays.    The  upper  row  are  concave  cathodes ;  the  lower  rows  are  flat. 
from  left  to  right,  is  shown  the  progressive  increase  in  the  production  of  the  cathode  rays  as  the 
pressure  <s  gradually  decreased.    (Bouchard.) 


FIG.  85.— Deflection  of  the  cathode  rays.    (Bouchard. ) 


THE  RONTGEX  BAY  APPARATUS. 


187 


The  rectilinear  propagation  of  the  cathode  rays  is  represented  in 
Fig.  87,  where  the  cathode  C  throws  the  shadow  of  the-  mica  cross  A 
ou  the  wall  of  the  tube  A'.  Arouiid  the  shadow  A'  the  tube  shows  a 
pronounced  phosphorescence. 


A" 


FIG.  8fi.—  Illustrating  the  effect  of  one  cathode  and  several  anodes  under  different  degrees  of 

vacuum.    (Bouchard.) 

A  Crookes  vacuum  tube  is  an  apparatus  wherein  electrical  energy  is 
transformed  into  X-rays.  These  tubes  present  various  shapes  and  modi- 
fications, according  to  the  requirements  demanded.  The  essential  in 


FIG.  87. — Illustrating  one  of  the  phenomena  in  high  vacua, — the  rectilinear  propagation  of 
the  cathode  rays.     (Bouchard.) 

the  design  of  an  X-ray  tube  includes  a  cathode  of  such  shape  as  to  focus 
the  cathode  rays  on  a  plate  of  dense  metal,  such  as  platinum,  which  either 
is  the  anode  or  is  placed  near  to  it. 

Fig.  88  is  the  illustration  of  such  a  tube.     The  cathode  rays  repre- 
sented by  the  shaded  area  focus  at  a  point  on  the  anode,  and  at  this  point 


l.ss 


ELECTRO-THERAPEUTICS. 


the  X-rays  originate,  and  from  it  radiate  in  every  direction  in  straight 
lines  as  light  rays  do  from  a  source  of  light.  They  are  represented  by 
broken  lines.  As  platinum  is  not  transparent  to  them,  they  are  found 
only  on  one  side  on  the  plane  of  the  platinum  and  are  practically  of  equal 
intensity  throughout  that  zone.  If  the  platinum  plate  were  absolutely 
true  and  polished  such  would  be  strictly  the  case.  As  it  is,  in  practice. 
the  rays  are  of  equal  intensity  down  to  about  ten  degrees  from  the  plane 
of  the  platinum.  In  the  majority  of  cases  they  are  made  of  German  soda- 
flint  glass,  which  presents  an  apple-green  color,  due  to  the  fluorescence 
produced  by  the  X-rays  under  vacuum,  this  glass  being  extremely 

transparent  to  the  X-rays.  Tubes 
made  of  soft  lead-glass  give  a  pale 
blue  fluorescence,  the  lead  acting  as 
a  barrier  to  the  passage  of  the  rays, 
hence  this  kind  of  glass  is  not  so 
desirable.  Other  varieties  of  glass 
fluoresce  in  different  colors. 

The  tube  consists  of  a  glass  bulb 
containing  a  single  platinum- faced 
target  and  one  or  more  aluminium  - 
faced  cathodes. 

The  anodes  and  cathodes  are 
connected  to  outside  terminals  by 
means  of  platinum  wires  which  are 
encased  by  the  extended  glass  stems, 
the  latter  being  fused  during  the  pro- 
cess of  blowing.  Oiten  tubes  are  pro- 
vided with  an  auxiliary  anode,  which 
is  invariably  made  of  aluminium. 

In  order  that  the  shadow-picture 
may  be  sharply  defined,  the  cathode 
rays  must  converge  or  be  focused  to 
a  point,  and  to  meet  this  requirement  the  aluminium  cathode  must  pre- 
sent a  concave  surface,  varying  in  diameter  from  \  to  1  inch  (.5-2.5  cm.). 
The  anode  ( ant i- cathode)  is  made  of  platinum,  and  may  have  a  varying 
diameter,  but  it  is  usual  to  have  its  plane  so  adjusted  as  to  form  an 
angle  of  45  degrees  to  the  cathode.  Placed  in  this  position  the  anode 
behaves  like  a  reflector,  receiving  and  throwing  off  the  rays  emitted  from 
the  cathode.  Platinum  has  a  high  fusing  point,  and  it  is  superior  in 
this  respect  to  all  ordinary  metals;  its  use  as  the  target  for  the  cathode 
lK>mbardment  is  because  of  its  iufusibility.  Very  few  other  metals  may 
be  used  in  its  place.  The  most  important  of  these  substitutes  is  ind- 
ium, which  is  another  member  of  the  platinum  group  and  has  a  higher 


Fio.  88.— Essential  features  of  an  X-ray  tube. 


THE  RONTGEN  BAY  APPABATU&  189 

fusion  point  than  platinum  itself.  Osmium,  which  is  also  an  infusible 
metal  of  the  same  group,  might  be  used. 

Alloys  of  these  metals,  having  varying  percentages,  are  also  used. 

These  infusible  metals  are  to  be  backed  up  by  ordinary  metals  such 
as  copper  and  iron,  because  the  latter  are  less  expensive  and  readily  pro- 
vide a  large  radiating  surface  and  thermal  capacity  for  the  dissipation  of 
the  heat  produced  at  the  focus-point. 

The  cathode  is  made  of  aluminium,  because  this  metal  disintegrates 
least  and  causes  the  least  discoloration  on  the  walls  of  the  tube.  The 
Crookes  .tube  contains  a  very  high  vacuum, — one  millionth  degree  of 
atmospheric  pressure.  In  order  to  exhaust  these  tubes  approximately 
they  are  subjected  to  the  action  of  mercury  pumps.  When  a  sufficient 
vacuum  has  been  obtained,  the  small  glass  tube  that  projects  from,  and 
forms  part  of,  the  Crookes  tube  is  removed  from  the  pump  receiver,  by 
melting  it  off  and  sealing  it  with  the  aid  of  the  Bunseu  burner. 

A.  THE  VARIETIES  OR  TYPES  OF  VACUUM  TUBES. 

(a)  Stationary  Vacuum. 

(b)  SeJf -Regulating  ttlld  Regenerative. 

(a)  Stationary  Vacuum. — A  tube  with  a  stationary  vacuum  is  one 
whose  vacuum  cannot  be  altered  during  its  period  of  usefulness.     This 
marks  the  earliest    type.     The   Crookes   tube    was   originally  pyriform 
or  cylindrical,  and  contained  an  aluminium  cathode  within  a  glass  bulb. 
The  cathodal  streams  were  projected  on  the  extreme  opposite  side  of  the 
tube,  producing  a  peculiar  fluorescence.     In  order  to  focus  and  subse- 
quently reflect  these  rays  Prof.  Herbert  Jackson,  of  King's  College,  Lon- 
don, introduced  the  anode  (anti-cathode)  so  as  to  reflect  the  cathode 
rays.1     To  this  improved  tube  he   applied  the  name   " focus"   tube.2 
The  priority  of  this  modification  is  also  claimed  by  Shalleuberger.3    As 
the  degree  of  vacuum  in  this  type  of  tube  is  liable  to  vary  either  from  use 
or  disuse,  there  is  a  constant  danger  of  its  permanent  impairment.     If 
the  tube  be  too  hard  (high  vacuum),  there  is  danger  of  puncture,  and 
impossibility  of  X-ray  production.     If  the  tube  be  too  soft  (low  vacuum), 
the  rays  will  lack  the  required  penetrability. 

(b)  Self-Regulating  and  Regenerative. — In  this  type  of  tube  the  degree 
of  vacuum  is  changed  either  automatically  or  by  the  operator,  thus  allow- 
ing various  modifications  in  the  penetrability  of  the  rays.     This  can  be 
effected  by  the  action  of  gases  derived  from  absorbent  substances  ;  founded 
on    the   principle   that    certain  chemicals, — caustic   potash,    palladium, 

1  Jackson  was  the  first  experimenter  to  employ  a  curved  cathode. 

2  Elect.  Review,  London,  March  13, 1896 ;  the  Scientific  American,  April  4,  1896. 
'Elect.  World,  New  York,  March  7,  1896. 


190  KLK<  TK(  )-TH  KK  A  PKl  TI<  S. 

permanganate  of  potassium,  etc.,-  when  placed  in  an  auxiliary  bulb 
(low  vacuum),  liberate  gases  upon  the  application  of  beat  and  reabsorb 
them  upon  cooling. 

In  1S96,  Mr.  L.  T.  Sayen,  of  Philadelphia,  devised  a  self- regulating 
tube  which  has  been  placed  on  the  market  by  Queen  &  Co.  Its  principles 
are  as  follows :  A  small  bulb,  containing  a  chemical  giving  off  vapor  when 
heated  and  reabsorbiug  it  when  cool,  is  directly  connected  to  the  main 
tube,  and  surrounded  by  an  auxiliary  tube,  which  is  exhausted  to  a  vacuum 
of  low  resistance.  In  the  auxiliary  tube  the  cathode  is  opposite  tin-  al «  >ve 
mentioned  bulb,  so  that  any  discharge  through  it  will  heat  the  bulb  by 
the  bombardment  of  the  cathode  rays.  The  cathode  is  connected  to  an 
adjustable  spark  point,  the  end  of  which  may  be  swung  to  any  desired 
distance  from  the  cathode  (main)  tube.  The  coil  is  connected  as  usual 
to  the  main  tube,  which  has  been  exhausted  to  a  very  high  vacuum,  and 
consequently  has  a  resistance  equal  to  ten  inches  or  more  of  air.  When 
it  is  put  in  operation  the  high  vacuum  of  the  main  tube,  and  the  conse- 
quent high  resistance,  causes  the  current  to  take  the  path  of  least  resist- 
ance by  the  spark  point  and  the  auxiliary  tube,  and  to  heat  the  chemical 
in  the  small  bulb,  thereby  driving  off  the  vapor  which  it  contains  into 
the  main  tube.  This  will  continue  for  a  few  seconds  until  a  sufficient 
amount  of  vapor  has  been  driven  into  the  main  tube  to  permit  the  cur- 
rent to  go  through  it,  which  occurs  when  the  vacuum  has  been  reduced, 
until  the  resistance  of  the  main  tube  is  equal  to  that  of  the  spark-gap 
plus  the  small  resistance  of  the  auxiliary  bulb.  After  this  only  an 
occasional  spark  will  jump  across  the  gap  to  counteract  the  tendency 
of  the  chemical  to  reabsorb  vapor  and  raise  the  resistance  of  the  main 
tube.  The  tube  is  thus  maintained  at  a  constant  vacuum  while  running. 
When  the  current  is  stopped,  the  tube  returns  to  its  starting  condition  of 
high  vacuum. 

The  construction  of  the  tube  should  be  understood  before  used,  and 
is  as  follows  (Fig.  89):  The  large  bulb  "B"  contains  the  main  cathode 
and  platinum  reflecting  plate.  The  regulating  bulb  "D"  is  connected 
with  the  main  bulb  "B."  The  cathode  "C"  in  the  main  bulb  is  com- 
posed of  hammered  aluminium,  moulded  to  an  exact  curve  of  such  ra- 
dius that  it  focuses  the  cathode  stream  on  the  anode  "A,"  which  is 
composed  of  platinum,  and  is  the  point  of  emission  of  the  X-rays. 

liull)  "  15"  is  exhausted  to  a  high  vacuum,  so  that  initially  no  elec- 
trical discharge  will  pass  through  it.  Bulb  "D"  is  exhausted  to  a  low 
Crookes  vacuum. 

Within  bulb  "D"  is  a  small  pear-shaped  bulb  "X."  in  communica- 
tion with  bulb  "B"  and  containing  a  chemical  capable  of  giving  off 
\apor  \vhen  heated  and  reabsorbing  it  \\hencooled.  A  small  cathode  in 
bulb  "D"  is  arranged  so  that  the  discharge  will  heat  this  bulb  "X." 


THE  RONTGE^  KAY  APPARATUS. 


191 


Attached  to  this  cathode  is  an  adjusting  spark-point  "P,"  the  end  of 
which  may  be  swung  to  any  desired  distance  from  the  terminal  of  the 
cathode  "C/' 

When  put  in  operation  the  high-  potential  secondary  current  will  not 
initially  pass  through  the  bulb  u  B"  on  account  of  its  high  vacuum,  but 
chooses  a  path  from  "K"  to  "P,"  through  the  bulb  "D,"  heating  the 
chemical  in  the  small  bulb  "X,"  causing  vapor  to  be  given  off  and  re- 
ducing the  vacuum  in  the  main  bulb  "B"  until  finally  it  becomes  suffi- 
ciently lowered  so  that  the  discharge  passes  through  the  bulb  "B" 
entirely,  producing  X-rays  from  the  plate  "A." 

Let  the  spark-point  "P"  be  separated  about  three  (3)  inches  from 
terminal  "K."  Start  coil  with  small  current  flowing  through  primary 
until  sparks  begin  to  jump  vigorously  between  UP"  and  "K."  Then 


FIG.  89.— Queen's  self-regulating  tube. 

open  the  primary  circuit  without  changing  its  adjustment.  Immediately 
close  again  for  a  second  or  so,  the  spark  passing  from  "P"  to  "K" 
through  and  lighting  up  the  small  regulating  bulb  "D."  Continue,  alter- 
nately, opening  and  closing  the  primary  circuit,  allowing  the  regulating 
bulb  "X''  to  heat  slowly  until  a  green  light  begins  to  show  in  the  main 
bulb  UB."  Hold  primary  circuit  open  for  a  second  or  two,  close,  and 
the  bulb  UB"  will  then  automatically  maintain  its  vacuum  at  the  set 
point,  the  primary  current  may  be  increased  to  the  full  capacity  of  the 
tube,  while  only  an  occasional  spark  will  pass  between  "P"  and  UK." 
1C  the  bones  appear  in  fluoroscope  too  black,  make  the  gap  between  lt  P' 
and  "K"  greater.  If  not  enough  distinction  between  bones  and  flesh, 
make  less. 

When  tube  is  running  properly,  the  main  bulb  will  be  filled  with  a 
brilliant  green  light,  with  a  sharp-cut  zone  through  the  plane  of  the 
platinum  plate,  the  upper  section  being  more  brilliant  than  the  lower. 


1!>L>  ELECTRO-THERAPEUTICS. 

Miiller,  of  Hoinburg,  and  E.  Ducretet,  of  Paris,  have  brought  forward 
a  tube,  resembling  in  many  respects  the  Sayeu  tube,  but  differing  from  it 
in  that  the  regulating  discharge  passes  directly  into  the  auxiliary  tube  ; 
the  latter  containing  caustic  potash.  (Fig.  90.)  When  the  vacuum  in  the 
main  tube  becomes  too  high,  and  consequently  the  resistance  too  great. 
the  current  passes  into  the  auxiliary  chamber,  whereby  the  potash  be- 
comes heated  aud  emits  vapor  ;  this  vapor  diffuses  itself  through  the  main 
tube,  thus  lessening  the  too  great  resistance.  Attached  to  the  auxiliary 
circuit  is  a  lever  that  regulates  the  interval  of  the  spark-gap  ;  the  more 
distant  the  lever  from  the  cathode  of  the  main  tube,  the  higher  the  vac- 
uum in  that  tube  ;  the  nearer  the  cathode,  the  lower  the  vacuum. 

Should  the  resistance  in  the  main  tube  be  in  excess  of  that  of  the 
spark-gap,  the  current  takes  the  path  of  lesser  resistance  and  passes 


K— 


Fro.  90.— Miiller's  regulation  tube. 

through  the  side  tube.  The  presence  of  sparks  in  the  spark-gap  shows 
that  the  process  is  proceeding.  Should  the  vacuum  in  the  main  tube  be- 
come too  low  (soft),  disconnect  the  wire  from  the  anode  of  the  main  tube 
and  attach  it  to  the  terminal  of  the  electrode  in  the  auxiliary  chamber. 
The  discharge  that  passes  under  this  adjustment  causes  metallic  particles 
to  be  driven  against  the  sides  of  the  tube  and  the  generation  of  more  gas 
to  be  occluded  on  the  electrode  (auxiliary).  Thus  the  vacuum  of  the 
tube  may  be  materially  raised. 

In  order  to  clarify  the  alx>ve  statements,  it  may  be  stated  that  the 
auxiliary  tube  "B"  contains  an  electrode,  "C,"  of  a  substance  which  will 
give  off  a  certain  quantity  of  gas  by  the  electric  discharge  passing  through 
it.  and  will  thus  lower  the  vacuum.  This  is  effected  by  approaching  the 
wire  "E"  to  the  cathode  "K"  aud  thus  permit!  in-  the  spark  to  pass. 
In  case  an  even  degree  of  hardness  is  to  be  maintained,  the  distance  of  the 


TIN-:  ROXT<;K.\  RAY  APPAR.YTIS. 


193 


wire  UE"  from  '•  K"  for  hard  rays  t  diagrams  of  the  pelvis  is  10-11  cm., 
for  soft  rays  ('diagrams  of  the  hand)  5-7  em.,  for  treatment  even  less. 
The  working  of  the  "Miiller  regulation"  maybe  observed  by  the  sparks 
passing  between  '  •  E  "  and 


"K."  As  sooii  as  this 
stops,  the  tube  has  the  de- 
sired degree  of  vacuum  and 
will  maintain  the  same  <m- 
ioiiKificn//!/  by  an  occasional 
spark  jumping  over  and 
reducing  the  vacuum,  as 
soon  as  the  latter  shows  a 
tendency  to  rise.  In  case 
the  automatic  way  of  lower- 
ing the  vacuum  should  re- 
quire  too  much  time,  it  can 
be  hastened  by  either  ap- 
proaching the  wire  "E" 
even  closer  to  "K,"  or 
finally  connecting  the  nega- 
tive  pole  to  the  loop  "C." 
In  this  latter  event  special 
caution  is  recommended,  as 
tubes  easily  become  too 
soft  and  a  hardening  is 
more  difficult. 

Hardening  a  tube  is 
effected  by  changing  the 
positive  pole  from  4<G"  to 
"J"  and  removing  the 
wire  "E"  far  off  from 
"K."  When  the  current 
is  now  turned  on,  it  will 
scatter  atoms  of  the  metal 
of  the  electrode  UJ,"  thus 
reabsorbing  part  of  the  gas 
of  the  tube.  This  process 
requires  up  to  5  minutes, 


B 


H 


FIG.  91.— Monopol  tube.  The  vacuum  may  be  altered 
during  the  process  by  the  generation  of  air  through  the 
disconnection  of  the  movable  conductor  "Z,"  or  by  the  ab- 
sorption of  air  through  the  disconnection  of  the  movable 
conductor  "H."  The  flexible  wire  "Z"  is  raised  for  some 
seconds  by  means  of  an  isolated  rod  until  a  spark  leaps  over 
to  the  auxiliary  cathode  at  "B,"  by  means  of  which  air  is 
generated  and  the  resistance  of  the  tul>e  lowered.  Tubes  in 
which  the  degree  of  generation  has  become  excessive  are 
modified  by  raising  the  movable  conductor  "  H  "  as  shown  in 
the  sketch.  Air  is  generated  by  the  disconnection  of  the 
flexible  conductor  "Z"  and  the  leaping  over  of  sparks  to 
"B,"  and  accordingly  the  degree  of  the  vacuum  in  the  tube 
is  lowered.  Air  is  absorbed  by  disconnecting  the  flexible 
conductor  "  H,"  and  the  resistance  of  the  tube  is  increased. 


according  to  the  vacuum, 
and  may  have  to  be  repeated.  It  is  not  advisable  to  change  the  vacuum 
of  a  tube  too  often.  For  different  purposes  different  tubes  should  l>e  em- 
ployed. Tubes  of  varying  construction  have  recently  been  brought  forth1 


1  Archives  of  Physiological  Therapy,  September  and  October,  1905. 
IS 


194  ELECTKO-THEBAPEUTICS. 

that  are  worthy  of  brief  mention.  The  Mouopol  tube  made  by  Hirsch- 
niann  of  Berlin  is  especially  devised  for  easy  regulation  of  the  vacuum 
without  interruption  of  the  X-rays.  (Fig  91.)  Using  a  spintermeter 
with  ball  terminals,  he  finds  that  each  centimeter  of  spark  equivalent 
practically  corresponds,  with  this  tube,  to  the  same  number  of  the  Benoist 
scale  of  penetration.  It  is  a  biauodal  tube,  with  a  separate  bulk  at  the 
cathode  end  for  lowering,  and  another  at  the  anode  end  for  raising  the 
vacuum,  and  either  of  these  may  be  caused  to  operate  by  simply  pulling 
its  movable  arm  with  an  insulated  hook.  This  may  be  done  while  the 
tube  is  in  operation. 

Heinz  Bauer  has  made  X-ray  tubes  in  which  the  rapid  raising  of 
the  vacuum,  due  to  the  pulverization  of  the  platinum  anti-cathode  is  pre- 
vented by  causing  the  current  to  pass  mostly  to  the  anode.  To  this  end, 
the  anode  is  pointed  and  contains  quite  a  mass  of  metal ;  besides  this,  a 
regular  small  self-induction  coil  is  placed  between  the  external  connec- 
tion of  the  anode  and  that  of  the  anti-cathode.  Another  of  Bauer's  t  ulx-s 
has  a  heavy  corrugated  copper  stem  for  the  auti -cathode,  dissipating  heat 
inside  the  tube,  and  also  externally,  through  a  reentrant  glass  tube  which 
forms  a  part  of  it. 

Method  by  Osmosis.  (Fig.  92. ) — This  method  depends  upon  the  prin- 
ciple that  heated  platinum  possesses  the  property  of  being  penetrable 
by  hydrogen.  A  closed  tube  of  platinum  is  sealed  into  the  bulb  of  the 


FIG.  92.— Osmosis  regulating  tube  of  Gundelach. 

X-ray  tube.  When  it  is  desired  to  lower  the  vacuum  in  the  tube,  the  pro- 
jecting platinum  tip  is  heated  to  redness  in  a  Bunsen  flame.  The  heated 
platinum  permits  the  passage  of  gas  through  its  pores  into  the  tube,  thus 
lowering  the  vacuum.  This  process  may  be  resorted  to  without  inter- 
fering with  the  working  of  the  tube ;  the  degree  of  vacuum  can  thus  be 
gauged  by  the  color  of  the  fluorescence.  A  low  vacuum  is  manifested 
by  a  bluish  tint,  indicating  that  the  heating  of  the  platinum  should 

cease. 

MecJuinical  Regeneration. — This  method  allows  of  a  variance  in  the 
penetration  value,  by  adjusting  the  distance  between  anode  and  cathode. 
Its  employment,  however,  is  inapplicable,  as  it  entails  the  sacrifice  of 
many  tubes  and  requires  an  adept  in  manual  dexterity. 


PLATE  I. 


SELF-REGULATING  X-RAY  TUBE.    OPERATING  PROPERLY. 
(FIG.  93.) 


THE  EOXTGEX  EAY  APPARATUS.          195 

Electro-static  Regeneration  is  founded  on  the  principle  that  the  dis- 
charge passing  through  a  focus  tube  is  influenced  by  the  charge  general e<l 
by  electro-static  induction  on  the  outer  surface  of  the  tube.  To  accom- 
plish this,  the  neck  of  the  tube  in  the  plane  of  the  cathode  edge  is 
covered  with  strips  of  tin-foil,  and  by  connecting  it  by  an  adjustable 
spark-gap  with  the  ground  or  wire  leading  to  the  cathode.  The  method 
gives  some  promise  of  usefulness,  but  the  serious  drawback  is,  the  con- 
stant danger  of  perforation  of  the  tube. 

Water-cooling  tubes  are  those  in  which  a  stream  of  running  water 
passes  around  the  anode,  maintaining  it  in  a  cool  condition,  thus  not 
interfering  with  the  degree  of  vacuum  in  the  tube.  In  other  tubes  there 
may  !*>  two  anodes  and  two  cathodes,  which  are  adapted  for  the  use  of 
the  alternating  current. 

B.  THE  QUALITY  OF  THE  X-RAYS. 

The  qualities  of  the  X-rays  depend  largely  upon  the  apparatus  and 
the  degree  of  vacuum  of  the  Crookes  tube.  Thus,  while  the  quantity  of 
the  electrical  energy  influences  the  intensity  of  the  rays  produced,  the 
condition  of  the  tube  is  the  predominating  factor  when  a  constant  and 
powerful  supply  of  X-rays  is  required.  Tubes  are  thus  said  to  be 
"soft,"  "hard,"  or  "medium." 

A  tube  is  said  to  be  "soft "  when  the  degree  of  vacuum  is  low,  thus 
offering  less  resistance  and  allowing  the  current  to  pass  easily,  but  with  a 
diminution  in  the  intensity  and  likewise  in  the  penetrability  of  the  rays. 

In  a  "hard"  tube  the  degree  of  vacuum  is  high,  resistance  is  there- 
fore increased,  and  a  greater  obstacle  is  presented  to  the  passage  of  the 
discharge.  The  radiation  gains  thereby  in  intensity,  as  also  does  the 
penetrative  power. 

The  "medium"  tube  occupies  a  place  intermediate  between  the 
••hard"  and  the  "soft." 

J.  M.  Eder  and  E.  Yaleuta1  observed  that  the  effectiveness  of  a  tube 
varied  with  its  degree  of  vacuum. 

Porter2  thus  classifies  the  rays: 

Xrrays  penetrate  the  soft  parts  easily,  but  the  bones  with  difficulty. 

X 2 -rays,  those  absorbed  by  the  soft  tissues. 

X  ,  rays,  those  readily  penetrating  both  soft  tissues  and  bone. 

Albers-Schouberg*  considers  four  degrees  of  vacuum : 

1 ,  hard  ( gra y ) .  3,  soft  ( deep-black) . 

2,  medium  eoft  (gray-black).  4,  very  soft. 

1  Vers.  n.  d.  Photo,  niittel-st  der  Rdntgenstr. ,  Wien  und  Halle,  1896,  p.  5,  Anm. 

2  Quoted  by  Valenta,  Oest.  Chemikerztg.,  I.  Nr.  I.  1898. 
'Fortsrhr.  a.  d.  Geb.  d.  ROntgenstr.,  I5<1.  iii.,  H.  4,  p.  143. 


196  ELE(  TK(  )-THEEAPEUTI(  \s. 

The  intensity  of  the  shadows  of  the  metaearpal  bones  on  the  fluor- 
escent screen  is  taken  as  an  index. 

Kienboek  recognizes  a  fifth  grade,  the  "over-hard"  tube.1 

The  success  in  skiagraphy  most  largely  depends  upon  the  quality  of 
the  rays  and  the  behavior  of  the  focus-tube. 

Until  the  present  time,  although  the  form,  size,  etc.,  of  the  tube 
have  steadily  improved,  the  majority  of  operators  will  sustain  me  when  I 
assert  that  in  order  to  make  a  good  skiagram  the  knowledge  of  the  decree. 
of  the  penetration  of  the  rays  is  most  essential. 

I  have  enumerated  the  various  methods  for  ascertaining  the  approxi- 
mate penetrability  (quality  and  quantity)  of  the  rays,  but  those  methods 
are  as  yet  quite  crude.  This  subject  is  fully  treated  of  under  Ilontgen 
Ray  Therapy. 

The  degree  of  the  vacuum  of  the  tube  changes  during  or  after 
active  work,  so  that  the  operator  cannot  predict  exactly  the  degree  of 
penetrability  of  the  rays;  hence  the  time  of  exposure  still  remains 
uncertain. 

Testing  the  rays  with  the  fluoroscope  by  the  shadow  of  the  bones 
of  the  hand  is  most  dangerous,  and  is  virtually  not  employed  to-day 
except  by  some  of  the  inexperienced  and  most  careless.  The  osteoscope 
of  Carl  Beck  substitutes  the  skeleton  hand  for  the  human  hand,  but  this 
is  injurious  to  the  eye,  no  matter  how  well  the  latter  is  protected  with 
lead  (flint)  glasses. 

Fluorescence  of  the  tube  is  an  inexact  measure,  and  the  degree  of 
redness  of  the  anode  is  unreliable.  Each  tube  behaves  differently  with 
different  types  of  interrupters,  currents,  and  coils. 

Spintermeter  or  Parallel  Spark-gap.  —  The  length  of  the  spark-gap  va- 
ries with  different  voltages  of  current,  the  shape  of  the  spark-gap,  the 
winding  of  the  coil ;  the  degree  of  the  vacuum  of  the  tube  or  its  resistance 
cannot  be  ascertained  because  of  the  distance  of  the  anode  from  cathode, 
and  the  varying  sizes  of  the  latter  may  cause  more  or  less  resistance. 

I  have  tubes  that  back  up  4  to  5  inches  (10  to  12.5  cm.)  parallel 
spark-gap,  and  yet  produce  cathode  rays  bluish  in  color  and  conical  in 
shape,  which  are  useless  for  penetration  ;  therefore  the  resistance  of  the 
tube  does  not  always  indicate  the  penetrability  of  the  rays." 

C.  CARE  OF  THE  TUBE. 

Before  using  the  tube  see  that  it  is  absolutely  free  from  dust  particles 
by  employing  some  soft  fabric  as  a  wiper,  exerting  as  little  pressure  on 
main  bulb  as  possible.  The  tube  should  always  be  perfectly  dried  by 
allowing  the  heat  from  a  gas  jet  to  pass'around  it. 

1  Wiener  klin.  Woch.,  1900,  No.  50. 
2 See  Part  III.,  Chapter  IV. 


PLATE  II. 


SELF-RK<;ri.ATlN(i   X  KAY  1TBK.     CTRREXT  RTXXIXG  IX  WRONG 

DIRECTIOX. 

(FiQ.  M.) 


THE  RONTGKN  RAY  APPARATUS.         197 

The  leads  from  the  terminals  of  the  secondary  coil  should  be  per- 
fectly insulated  and  sufficiently  separated  from  one  another  through- 
out their  entire  length  to  prevent  any  sparking  between  them.  These 
wires  must  not  come  in  contact  with  any  conducting  material,  which 
would  naturally  permit  of  leakage  of  the  current.  The  conducting  wires 
should  be  sufficiently  distant  from  the  surface  of  the  tube  to  prevent 
puncturing.  Such  a  puncture  is  usually  from  a  spark  jumping  through 
the  glass  wall  from  the  conducting  wire  to  the  electrode  within  the  tube 
of  opposite  polarity.  Puncture  of  the  tube  renders  it  useless,  in  some 
ruses  presenting  an  immediate  change  of  color.  Sparking  occurs  between 
the  anode  and  cathode  from  the  inrush  of  air  ;  in  other  cases  the  injured 
tubes  may  be  worked  for  two  or  three  hours  after  the  accident.  If  the 
auxiliary  bulb  lights  blue  or  red,  the  vacuum  is  low  and  a  puncture  or 
leak  may  be  suspected.  (Fig.  07.) 

In  operating  a  tube  see  that  the  current  is  sent  into  it  in  the  proper 
direction,  or  blackening  will  soon  occur  on  the  inside,  manifesting  itself 
by  disintegrating  platinum  particles.  Should  the  current  conductors  be 
connected  to  the  tube  in  reverse  order,  the  error  will  be  recognized  by  a 
brilliant  jumping  fluorescence  around  and  behind  the  platinum  target. 
With  proper  connections  there  is  a  steady  fluorescence  of  the  hemisphere 
in  front  of  the  anode.  As  the  X-ray  apparatus  is  provided  with  a  com- 
mutator, the  current  can  conveniently  be  reversed  without  altering  the 
connections  and  position  of  the  tube.  Figs.  93  and  94  illustrate  the 
proper  and  the  wrong  connection  of  the  tube. 

Blackening  of  the  Tube. — As  already  mentioned,  blackening  of  the 
tube  often  results  from  the  l  ( inverse' '  current,  but  this  can  be  avoided  by 
placing  the  spark-gaps  in  "series"  of  intervals  of  two  or  three  inches 
either  in  one  or  both  ends  of  the  terminals. 

Lately  I  have  seen  the  whole  inner  surface  of  the  tube  darkened  by 
an  impure  alkaline  substance  thrown  off  from  the  auxiliary  bulb.  The 
tube  was  opened,  and,  by  the  aid  of  an  acidulated  solution,  the  substance 
causing  the  discoloration  was  dissolved,  showing  that  the  blackening  was 
not  due  to  disintegrated  platinum  particles,  but  to  the  impurities  of  the 
potash  in  the  auxiliary  bulb.  Had  this  blackening  been  caused  by  the 
disintegration  of  the  anode,  the  discoloration  would  have  been  manifested 
only  at  the  active  hemisphere. 

In  place  of  the  spark-gap  in  "  series,"  Villard  urges  the  employ- 
ment of  a  veutril  tube  with  a  proper  degree  of  vacuum  for  the  current, 
.  instead  of  its  passage  through  the  air.  (Fig.  95.)  By  employing  the 
ventril  tube  the  current  becomes  unidirectional,  the  rays  have  a 
greater  penetrative  power,  blackening  is  minimized,  and  the  "  life  "  of  the 
tube  is  prolonged.  I  find  the  self-regulating  veutril  tube  to  be  eminently 
satisfactory. 


198  ELECTKO-TH  E I :  A  I '  1  •:  T  T I  ( 'S. 

Puncture  of  the  Anti-cathode. — This  accident  occurs  only  in  tubes 
with  very  thin  and  non-supported  anodes  :  especially  did  puncture  of 
the  anti-cathode  happen  when  the  Wehuelt  interrupter  first  came  into 
use.  This  difficulty  has  been  overcome  by  increasing  the  thickness  of 
the  anode,  and  also  by  reinforcing  it  in  back  by  means  of  copper  ;  like- 
wise by  making  the  converging  cathode  rays  fall  at  a  point  a  little  in 
advance  of  the  anode. 

Explosion  of  the  Tube. — When  a  tube  is  accidentally  broken,  the 
sudden  inrush  of  air  produces  a  report  resembling  that  accompanying 
the  explosion  of  a  firecracker.  I  believe  the  term  '-explosion"  is  a 
misnomer;  the  substitution  of  the  term  "  collapse"  would  appear  to  me 


FIG.  95.— Villard's  ventril  tube. 

to  be  more  correct,  for  the  general  breaking  up  is  more  likely  the  result 
of  external  atmospheric  pressure  than  due  to  any  force  created  inter- 
nally. In  the  experience  of  years  I  have  never  suffered  the  explosion  of 
a  tube. 

The  "life"  of  the  tube  depends  largely  on  the  amount  of  its  use, 
and  the  care  in  manipulation  bestowed  upon  it.  The  metallization  of 
the  tube  interferes  in  no  manner  with  its  working. 

In  regard  to  the  consumption  of  tubes  by  the  use  of  small  and  large 
inductors  the  conclusions  reached  by  Albers-Schonberg  are  of  the  greatest 
practical  importance.  He  has  kept  a  complete  record  of  the  use  of  each 
tube  and  the  conditions  under  which  it  was  used,  and  concludes  that  the 
life  of  a  tube  used  with  an  80  cm.  coil  is  more  than  three  times  as  long 
as  when  used  with  a  40  cm.  coil.  The  small  coil  used  in  this  instance 
was  the  Dessauer  instrument.  At  the  same  time  he  found  that  the  work 
done  by  the  tube  in  connection  with  the  large  coil  was  more  satisfactory. 
In  order  to  get  the  desired  results  with  the  small  coil  it  was  necessary  to 
use  a  ventril  tube  in  series  with  the  Kontgen  tube,  while  with  a  large 
coil  none  was  used. 

When  the  vacuum  becomes  so  high  or  so  low  (Fig.  96)  that  it  is 
pii-uited  for  the  operator's  purpose,  and  his  efforts  to  restore  a  proper 
vacuum  are  unavailing,  the  only  remedy  is  a  repumping  of  the  tube  by 
the  manufacturer. 


PLATE  III. 


SELF-REGULATING  X-RAY  TUBE.     LOW  VACUUM. 
(FIG.  96.) 


THE  RONTGEN  RAY  APPARATUS.  199 

III.   The  Fluoroscope  and  Accessories. 

A.    COXSTRrcTIOX    OF   THE   FLUOROSCOPE. 

The  fluoroscope,  also  called  cryptoseope  and  iristoscope,  was  devi>ed 
and  first  described  by  Professor  Salviui,  of  Rome.1  It  cousistvS  of  a  dark- 
ened chamber,  having  the  shape  of  a  photographic  camera.  At  the 
larger  end  is  fixed  the  fluorescent  screen;  at  the  smaller  end  is  an  opening 
(fitting  the  examiner's  forehead)  through  which  the  shadows  on  the 
screen  may  be  observed.  With  a  fluoroscope  a  darkened  room  is  unnec- 
essary. The  majority  of  fluoroscopes  are  provided  with  a  handle  for 
holding  the  apparatus.  More  recent  ones  are  so  constructed  as  to  permit 
of  the  easy  removal  of  the  screen.  (See  Fig.  104. ) 

The  fluorescent  screen  mentioned  above  consists  of  a  coating  of 
platino-cyanide  of  barium,  spread  evenly  upon  a  supporting  sheet.  A 
layer  of  varnish  is  carefully  applied,  so  as  to  prevent  this  fluoresciug 
material  from  falling  off,  and  likewise  to  keep  it  dry.  As  the  fluores- 
cence of  the  screen  is  not  very  brilliant,  a  dark  room  must  be  employed, 
otherwise  rays  of  ordinary  light  will  interfere.  The  screen  being  adjusted 
in  the  frame,  the  chemical  surface  further  protected  by  isinglass,  and 
the  light  excluded  from  the  tube  by  means  of  black  paper,  beautiful 
shadows  are  portrayed  by  placing  the  object  between  the  tube  and  the 
screen.  When  not  in  use  the  screen  should  be  kept  free  from  dust  and 
moisture. 

There  are  other  chemical  agents  besides  those  mentioned  which  pos- 
sess fluorescent  properties  and  are  adapted  for  screens.  Thus  Edison,  who 
examined  1800  chemicals,2  found  that  tuugstate  of  calcium  fluoresced  with 
six  times  more  intensity  than  platino-cyanide  of  barium;  next  in  bril- 
liancy was  tungstate  of  strontium.  Salicylate  of  ammonium  (crystals) 
fluoresces  as  much  as  double  cyanide  of  potassium  and  barium;  the 
former's  fluorescence,  however,  increases  with  the  increase  of  the  thick- 
ness of  the  crystal  layer.  Other  substances  that  fluoresce  under  the  ac- 
tion of  the  rays  are  mercurous  chloride,  caduiic  iodide,  calcium  sulphide, 
potassium  iodide,  potassium  bromide,  etc. 

The  only  two  of  the  many  fluorescent  salts  employed  in  the  manufac- 
ture of  screens  are  platiuo-cyanide  of  barium  and  calcium  tuugstate.  The 
former  affords  a  brilliant  yellowish -green  fluorescence,  the  latter  a  less 
intense  bluish-white.  This  bluish  white  fluorescence  offers  a  greater 
photo -chemical  activity,  and  is  therefore  employed  as  an  intensifying 
screen  in  radiographic  work.  Under  the  name  of  "the  collapsible 
cryptoseope,"  H.  W.  Cox  &  Co.,  Ltd.,  of  London,  have  placed  upon  the 

1  Proceedings  of  the  Accademia  Medico-Chirurgica  di  Perugia,  vol.  Hi.,  No.  1-2  ; 
also  the  Scientific  American,  March  28,  1896. 

2  Elect.  Review,  New  York,  April  19,  1896. 


200  ELECTRO-THERAPEUTN  S. 

market  a  fluoroscope,  which  apparatus  is  fitted  with  accordion  folds, 
that  readily  permit  of  easy  adjustment.  This  cryptoscope  has  gi ven 
satisfaction,  but  its  exorbitant  price  makes  us  general  employment 
prohibitory. 

B.  SKIAGRAPHIC  TABLE. 

A  skiagraphic  table  consists  of  a  strong  rectangular  frame  of  wood 
over  which  is  stretched  some  fabric,  or  thin  leather,  which  is  radio- 
scopically  transparent.  The  frame,  which  is  supported  by  four  uprights 
(one  at  each  corner)  18  to  20  inches  high,  may  be  covered  by  a  piece 
of  thin,  strong  board,  in  order  to  make  it  more  steady.  In  making  a 
screen  examination,  the  patient  is  placed  upon  the  couch  with  the  tube 
under  it,  the  rays  penetrating  from  below  upward.  In  taking  a  skiagram, 
the  sensitive  plate  is  placed  under  the  patient  and  the  tube  above,  the 
rays  passing  from  above  downward.  Do  not  move  the  screen  or  the  pa- 
tient if  a  skiagram  is  to  be  taken  after  making  a  screen  examination  : 
hence  an  adjustable  plate-holder  should  be  fitted  to  the  couch.  The  tube 
may  be  shifted  and  clamped  in  any  position. 

C.  HOFFMAN'S  MEASURING  STAND  AND  EXAMINING  FRAME. 

This  consists  of  two  uprights  firmly  secured  to  a  platform,  and  sup- 
porting the  square  or  rectangular  shaped  measuring  frame  which  can  be 
shifted  up  and  down  or  to  the  right  or  left,  by  turning  a  few  thumb-screws. 
The  adjustable  frame  is  subdivided  into  smaller  squares.  The  dividing 
cross-bars  are  so  constructed  as  to  permit  of  their  being  shifted  into  any 
position  and  their  exact  location  noted  by  reading  the  metric  scales  at 
the  sides.  Accessory  frames  are  placed  at  the  outside  of  the  uprights ; 
one  of  these  acting  as  a  plate-receiver  for  a  skiagram ,  another  supports 
the  fluoroscopic  screen  for  a  visual  examination. 

Lately  I  devised  a  table  that  meets  the  requirements  for  skiagraphy, 
stereo-skiagraphy,  and  X-ray  treatment.  (See  Figs.  183  and  184.)  It  is 
made  of  wood,  and  upon  the  two  parallel  horizontal  metallic  tubes,  t\v<> 
vertical  metallic  rods  move  to  and  fro,  the  latter  supporting  a  horizontal 
sliding  bar  of  wood,  from  which  is  suspended  the  tube-holder.  For  skia- 
graphy the  tube  can  be  placed  under  the  table,  over  the  table,  or  in  any 
position  in  relation  to  the  patient's  body.  The  table  is  provided  with 
an  adjustable  plate-holder.  The  device  can  be  regulated  so  as  to  be 
adapted  to  any  sized  plate  ;  it  is  attached  to  the  vertical  rods.  This  plate- 
holder  with  the  plate  is  placed  over  the  part,  with  the  tube  beneath  the 
table,  or  in  the  sitting  posture  the  plate  is  placed  against  the  part,  and 
the  tube  behind  the  patient.  In  stereo-skiagraphy  the  plates  can  be 
changed  without  employing  the  usual  drawer.  For  treatment,  the  tube 
is  placed  in  a  leaden  lined  wooden  box,  having  an  adjustable  diaphragm 


PLATE  IV. 


SELF  REGULATING  X-RAY  TUBE.     PUNCTURED  OR  CRACKED. 
BULB  PARTIALLY  FILLED  WITH  AIR. 

(Fro.  97.) 


THE  BONTGEN  KAY   A  I'l'A  I  {ATI'S.  201 

with  any  required  sized  opening,  which  is  regulated  by  sliding  the  mov- 
able pieces  of  wood  composing  it.  The  burs  and  tubings  are  scaled  in 
inches  and  centimeters  to  facilitate  the  ease  of  measurements  required  of 
the  operator. 

D.  TUBE-HOLDERS. 

These  are  of  various  kiuds.  For  clinical  purposes  it  is  essential  to 
have  a  stand,  in  order  that  the  tube  may  be  adjusted  to  any  desired  height 
from  the  floor,  at  the  same  time  allowing  it  to  project  far  enough  to  en- 
able to  operator  to  shift  it  at  ease  over  the  examining  table  or  couch. 
The  base  must  be  heavily  weighted,  to  insure  steadiness,  and  the  project- 
ing arm  must  be  firmly  clamped.  The  latter  is  made  of  wood  or  ebonite 
to  prevent  any  spark  from  the  terminals  passing  into  the  metal  and  thus 
perforating  the  tube.  Loose  clamping  must  be  studiously  guarded 
against ;  lack  of  this  precaution  will  produce  a  blurred  photograph,  as 
the  swinging  tube  is  made  readily  tremulous  by  the  amplification  of  any 
motion  communicated  to  the  stand  and  arm. 

The  majority  of  tube-holders  slide  on  a  horizontal  bar,  the  latter 
being  supported  by  two  vertical  ones,  or  it  may  have  independent  sup- 
port from  a  heavy  iron  tripod  on  the  floor.  The  disadvantage  of  these 
constructions  is  that  the  tube  may  move  or  shake  if  attached  to  the  table, 
it  is  clumsy  to  handle,  occupies  too  much  space,  and  stands  in  the  way  of 
the  operator.  In  offices  a  couch  can  be  used  as  a  table.  It  is  soft  and 
convenient,  and  is  useful  for  therapy  and  examinations.  Above  the 
couch,  attached  to  the  wall,  are  two  wooden  rods  grooved  on  their  inner 
surfaces.  A  square  block  of  wood  slides  between  the  grooves  of  these  two 
rods,  the  whole  being  supported  on  brackets.  Attached  to  this  square  of 
wood,  and  at  right  angles  to  it,  is  screwed  a  movable  rod,  which  by  tight- 
ening or  loosening  the  screw  can  be  adjusted  to  any  angle.  This  last  rod 
has  a  small  sliding  transverse  block  of  wood  through  which  passes  the 
vertical  metallic  rod,  holding  the  clainp.  A  similar  metallic  rod  is 
attached  to  a  sliding  rod  for  supporting  a  leaden  screen,  which  protects 
the  operator. 

Lately  I  devised  a  tube-holder  in  my  office  made  up  as  follows  :  A 
shelf,  made  of  two  horizontal  bars  grooved  in  their  interior,  is  bracketed 
upon  the  wall.  Along  these  grooves  slides  a  block  of  wood  (the  carriage). 
To  this  carriage  is  attached  a  projecting  bar  of  wood,  whose  angle  may 
be  varied  at  pleasure  by  adjusting  the  thumb-screw  maintaining  its  rela- 
tion with  the  carriage.  By  means  of  an  adjustable  screw,  a  second  block 
of  wood  (transverse  to  the  long  axis  of  the  projecting  bar)  is  made  to  slide 
to  and  fro  at  the  will  of  the  operator.  Through  this  latter  bar  runs  the 
metallic  rod.  supporting  the  tube-holder.  By  means  of  this  holder,  free- 
dom of  movement  is  so  obtained  that  the  principles  of  the  universal  joint 


202  KLE(  TRO-THERAPKUTICS. 

are  faithfully  portrayed.  With  this  tube-holder  the  table  is  dispensed 
with,  and  a  couch  or  sofa  is  substituted  upon  which  a  board  is  placed  it' 
necessary,  for  supporting  the  sensitive  plate.  (See  Fig.  200.) 

E.  BOX-COVER  FOR  X-EAY  TUBE. 

This  consists  of  n  wooden  box  covered  ou  its  inner  surface  l»y  a  thick 
coating  of  lead  oxide.  On  one  side  of  this  box  is  a  hole  (4  to  5  cui.  in 
diameter)  for  the  transmission  of  the  rays.  This  circular  aperture  is 
shielded  by  a  wooden  diaphragm  of  heavy  sheet  lead,  having  three  differ- 
ent sized  apertures,  and  by  adjustment  the  desired  opening  can  be  brought 
in  direct  line  with  any  part  of  the  body.  Luminous  effects  are  excluded. 
and  the  dangers  of  burning  by  the  rays  are  reduced  to  a  minimum.  It 
must  be  remembered  that  the  diameter  of  the  rays  (cone-shaped 
increases  as  the  distance  the  tube  is  placed  from  the  patient. 

In  some  tube  boxes,  instead  of  the  lead  foil,  several  layers  of  lead 
paint  are  used  for  coating  the  interior  of  the  box.  The  size  of  the  box 
varies  in  different  models.  In  some  instances  they  are  made  so  large  as 
to  be  an  inconvenience,  while  in  other  cases  they  are  too  small  to  secure 
perfect  insulation. 

F.  DIAPHRAGM. 

The  diaphragm  was  formerly  used  for  sharpening  shadows  ou  sensi- 
tive plates.  It  may  be  made  of  metal  or  glass,  with  an  aperture  in  the 
centre  for  the  transmission  of  the  rays.  In  the  glass  variety,  the  excess 
of  lead  acts  as  an  obstacle  to  their  passage,  the  rays  being  almost  wholly 
transmitted  through  the  aperture.  If  the  diaphragm  is  metal,  it  should 
preferably  be  grounded,  to  obviate  the  danger  of  puncturing  the  tube  by 
sparks  jumping  from  it.  The  object  of  the  diaphragm  is  to  prevent  the 
passage  of  the  rays  to  other  parts  than  those  examined. 

Compression  Diaphragm. — This  appliance,  devised  by  Albers-Schon- 
berg,  consists  of  a  metallic  tube,  having  one  end  applied  against  the  part 
to  l>e  skiagraphed,  and  the  other  end  so  adjusted  as  to  receive  the  rays 
emanating  from  the  Crookes  tul>e.  By  its  use  we  secure  immobility  of 
the  part,  mechanically  lessen  the  thickness  of  the  structures  under  exanii 
nation,  and  totally  exclude  all  the  secondary  rays.  (Fig.  09.)  In  Fig. 
98  is  illustrated  the  ordinary  diaphragm,  wherein  is  depicted  the  passage 
of  the  indirect  rays,  b  b,  affecting  that  portion  of  the  plate  indicated  by 
the  slanting  parallel  lines;  this  is  entirely  obviated  in  the  compression 
diaphragm,  where  a  a  are  the  direct  rays  from  the  anode.  (See  also  Figs. 
192  and  193.) 

Dr.  Henry  Hulst1  states  that  the  use  of  this  diaphragm  is  most  valu- 
able in  the  skiagraphy  of  renal,  spinal,  and  pelvic  conditions.  Thus,  in 

•Transactions  of  the  American  Runt-gen  Ray  Society,  September,  1905. 


THE  ROXTGEX  KAY  APPAR ATI'S. 


203 


cases  of  suspected  renal  calculi,  the  employment  of  the  compression  dia- 
phragm materially  lessens  the  number  of  diaphragmatic  movements  of 
the  patient,  and  as  the  kidney  moves  with  each  movement  of  the  patieut's 
diaphragm,  the  steadiness  of  the  kidney  is  markedly  increased,  in  conse- 
quence of  which,  a  skiagram  of  a  renal  calculus  will  not  be  blurred. 

The  serious  disadvantage  of  the  compression  diaphragm  is  the  fact 
that  only  a  very  small  area  cau  be  skiagraphed  at  one  time,  while  the 


II 


FIG.  9s— ordinary  diaphragm. 


FIG.  99.— Tubular  or  compression 
diaphragm.    (Donath.) 


stone  searched  for  may  be  located  outside  the  part  covered  by  the  cylin- 
der. This  method  prevents  a  negative  being  taken  of  both  sides  for  the 
sake  of  comparison  ;  a  most  necessary  and  invaluable  guide. 

Although  largely  used  in  Europe  and  America,  I  do  not  advocate 
the  employment  of  a  compression  diaphragm,  as,  with  greater  refinements 
in  the  technic,  the  time  of  exposure  has  been  so  materially  lessened  that 
there  is  a  marked  decrease  of  the  secondary  rays,  and  without  the 
diaphragm  a  large  area  is  exposed  for  examination  on  the  plate. 

IV.  The  Selection  and  Installation  of  X-ray  Apparatus. 
A.  SELECTION"  OR  CHOICK. 

In  equipping  an  X-ray  laboratory  several  factors  must  be  considered. 
The  scope  of  the  work,  the  portability  of  the  instrument,  the  necessary 
expenditure  that  will  be  incurred,  the  requirements  of  the  apparatus  for 
the  office,  the  city  or  country  hospital,  and  the  fact  whether  the  purchaser 
is  an  X-ray  specialist  or  a  general  praetitioiier. 

By  the  scope  of  work  to  be  accomplished  we  mean  the  extent  of  use- 
fulness of  an  X-rav  outfit.  A  small  coil  will  suffice  for  the  work  that  a 


204  ELK<  T IH  >-T  1 1  K II A I ' KUTICS. 

beginner  may  be  required  to  do,  but  the  purchase  in  the  beginning  of  a 
large  coil,  which  will  prove  more  lasting,  is  wisest  because  increase  of 
work  will  early  demand  this  improvement  in  the  apparatus. 

Hospital  (City  or  Country). — In  the  majority  of  city  hospitals  a  110- 
volt  current  is  supplied  for  working  a  coil.  The  coil  that  is  installed 
in  the  laboratory  of  a  large  city  hospital  should  have  a  spark  length  of 
from  lii  to  20  inches  (30  to  50  cm.).  It  should  be  so  constructed  as  to  be 
capable  of  conveyance  to  the  various  parts  of  the  hospital.  The  coil 
can  be  worked  by  attaching  a  connecting  head  to  one  of  the  electric  light 
sockets  from  which  leads  extend  to  the  coil.  If  the  hospital  is  not  lighted 
by  electricity  (110-volt  current),  it  becomes  necessary  to  prepare  a  place 
on  the  main  shelf  of  the  carriage,  or  on  the  second  shelf,  for  placing  a  stor- 
age battery,  by  which  means  the  coil  then  must  be  worked.  When  patients 
can  be  conveyed  from  the  bed  to  the  laboratory,  much  labor  is  saved. 

In  country  hospitals  and  sanitaria,  where  there  is  difficulty  in  obtain- 
ing either  continuous  or  alternating  current,  static  machines  are  recom- 
mended for  exciting  the  Crookes  tube,  and  also  for  therapeutic  purposes. 
For  exciting  a  tube  the  use  of  a  water  motor  or  a  small  gasoline  or  gas 
engine  must  be  resorted  to.  If  expense  be  a  matter  of  moment,  I  then 
recommend  a  coil  worked  by  a  secondary  battery.  The  physician's  or 
surgeon's  outfit  should  be  portable.  He  should  employ  an  8-  to  10-inch 
(20-25  cm.)  spark,  worked  by  a  storage  battery.  For  examinations  in 
a  private  office  the  use  of  a  static  machine  (run  by  an  electric  motor),  in- 
stead of  a  coil,  is  recommended.  The  expert  should  have  in  his  posses- 
sion an  outfit  capable  of  meeting  all  emergencies.  It  should  consist  of 
two  coils  and  a  static  machine.  In  his  private  office  he  should  have  a 
stationary  coil  with  a  spark-producing  power  of  from  18  to  22  inches 
(45  to  55  cm. ),  and  a  second  coil  so  constructed  and  arranged  as  to  allow 
of  its  ready  transportation,  the  latter  to  be  capable  of  giving  a  spark 
from  8  to  10  inches  (20-25  cm.)  long.  This  portable  coil  should  be 
worked  with  a  storage  battery. 

Portable  Outfits. — The  necessity  of  moving  an  X-ray  apparatus  re- 
quires the  outfit  to  be  as  compact  and  light  as  possible.  In  the  latest 
forms  of  apparatus  the  coil  and  accessories  are  carefully  fitted  into  a  case 
which  makes  it  readily  transportable.  The  cumbersome  storage  battery 
must  be  conveyed  separately  with  the  coil,  etc.  The  latter  should  be  8 
to  lo  inches  (20  to 25  cm.).  The  more  recent  accumulators  are  very  light 
and  compact. 

B.    INSTALLATION. 

It  remains  to  give  a  brief  resume"  of  the  arrangement  and  manage- 
ment of  the  different  parts  concerned  in  the  production  of  a  skiagraph. 
The  first  essential  is  to  determine  the  nature  of  the  current  available. 


THE  RONTGEN  RAY  APPARATUS. 


205 


The  coil  can  be  eiiergized  by  an  accuiaulator  or  by  the  continuous  or 
alternating  current  from  the  street  supply.  In  the  latter  instance  the 
transformer  is  necessary  to  reduce  the  enormous  voltage.  Some  place  the 
coil  upon  the  table  ;  my  own  preference  is  to  rest  it  upon  a  shelf  attached 
to  the  wall,  thus  space  is  saved  and  the  operator  is  kept  away  from  the 


S.  Coil 


FIG.  100.— AUTHOR'S  TABLE  AND  TUBE-HOLDER.— The  pulley  moves  the  tube-holder  to  and  fro. 
The  ventril  tube  is  connected  in  series  with  the  Crookes  tube  and  lessens  the  "  reverse  current,"  whose 
vacuum  can  be  lowered,  at  pleasure,  by  the  operator  compressing,  at  a  distance  from  the  tube,  a  bulb, 
which  drives  a  blast  of  air  into  a  gas  flame,  thus  allowing  the  heating  of  the  platinum  in  the  ventril 
tube. 

magnetic  field.  The  latter  method  is  prevalent  in  Germany.  The  con- 
trolling apparatus  (the  interrupter,  rheostat,  switch-board,  etc.)  should 
be  within  easy  reach.  After  installing  the  coil,  the  source  of  current  ran 
be  connected  with  it  by  the  use  of  the  switch -board.  The  switch-board 
is  provided  with  several  binding  posts,  the  latter  being  connected  with 


206 


ELECTBO-THEKAPEUTICS. 


^- 


THE  EOXTGEX  RAY  APPARATUS. 


207 


tlie  accumulator  and  likewise  with  the  direct  current.  A  double  switch- 
thrower  connects  the  current  with  either  the  accumulator  or  the  direct 
current.  Another  switch  can  be  made  to  connect  the  current  with  either 
the  mechanical  interrupter  or  the  Wehuelt  break.  For  charging  the 


FIG.  102.— Author's  office  outfit. 

accumulator  a  bank  of  lamps  is  provided  ;  the  remainder  of  the  switch- 
board is  made  up  of  the  fuses,  the  ammeter  and  the  voltmeter.  The 
author's  table  and  tube-holder  and  method  of  installation  are  illustrated 
in  Figs.  100,  101,  and  102. 

C.  POLARITY  AND  CONNECTION  OF  TUBE. 

Next  to  be  considered  is  the  connection  of  the  terminals  of  the  sec- 
ondary coil  to  the  tube.  To  do  this  properly  it  is  necessary  to  ascertain 
the  polarity.  The  following  methods  may  be  applied  : 

(1)  Dip  the  ends  of  the  two  wires  into  dilute  sulphuric  acid  or 
water.     The  negative  wire  shows  a  free  development  of  gas;  this  does  not 
occur  with  the  anode,  which  is  colored  black  from  the   deposition  of 
copper  oxide. 

(2)  Moisten  the  paper  with  potassium  iodide,  bring  the  poles  in 
contact  with  it;  the  presence  of  a  black  stain  indicates  the  anode. 

(3)  By  means  of  a  small  tube  filled  with  a  liquid  into  which  plat- 
inum wires  project;  the  application  of  a  negative  pole  is  followed  by  the 
liquid  being  dyed  a  red  color. 

(4)  The  polarity  can  also  be  determined  by  the  peculiar  color  of 
the  spark  on  the  terminal  electrodes  of  the  secondary  coil  ;  the  cathode 
shows  the  presence  of  a  thick,  whitish  spark,  while  the  anode  shows 
several  wiry  lines  of  spark  of  a  pink  color.     (Fig.  103.) 


208  ELECTRO-THEKAPEUTICS. 

The  leading  wires  should  be  connected  with  the  proper  terminals  of 
the  tube  by  thin,  well- insulated  copper  wire.  This  connection  to  the 
terminals  should  be  provided,  on  each  side,  with  at  least  one  inch  of 
spark-gap.  The  wires  should  be  separated  at  a  distance  from  each  ether, 
from  the  tube,  and  also  the  patient,  greater  than  the  length  of  the  parallel 
spark-gap  (where  the  wires  are  attached  to  the  tube  they  are  supported 
by  a  non-conductor).  The  current  must  not  be  turned  on  before  all  con- 
nections are  completed,  else  there  is  danger  of  severe  shock  both  to  the 
operator  and  the  patient.  "Wrong  polarity  can  be  easily  determined  by 
the  appearance  of  the  tube,  and  corrected  by  the  commutator. 

After  the  polarity  has  been  ascertained  the  ends  of  the  tube  may  be 
connected  to  the  respective  terminals.  The  connecting  wires  should  l»e 
thickly  coated  with  gutta-percha  to  prevent  leakage  and  also  possible 
puncture  of  tube.  There  should  exist  multiple  spark-gaps  in  series,  as 


FIG.  103.— The  polarity  as  determined  by  the  appearance  of  the  spark. 

this  device  improves  the  quality  of  the  rays  and  prevents  or  lessens  the 
"  inverse  "  current  within  the  tube.  After  the  tube  has  been  lit  up,  the 
spark-gap  between  the  ends  of  the  tube  and  the  brass  balls  should  be 
adjusted  until  the  best  results  are  obtained. 

Advantages  of  the  Static  Machine. — The  static  machine  requires  little 
attention  and  is  nearly  always  ready  to  generate  electrical  energy,  of  a 
high  potential.  The  current  is  almost  perfectly  continuous  through  the 
tube,  and  hence  the  illumination  of  the  fluoroscope  is  steady.  The  radi- 
ation and  the  penetration  of  the  rays  of  the  tube  may  be  modified  by 
varying  the  interval  of  the  spark-gap  (in  series).  The  static  current 
may  also  be  used  as  a  therapeutic  agent. 

Disadvantages  of  the  Static  Machine. — Should  the  beginner  purchase  a 
coil  or  a  static  machine  for  X-ray  work  ?  A  definite  answer  cannot  be 
given  unless  the  scope,  kind,  and  the  place  of  work  be  considered.  I 
employ  both  the  static  machine  and  the  coil,  the  static  for  electro-thera- 
peutic purposes,  and  the  coil  for  X-ray  work.  I  have  stated  the  merits 
and  demerits  of  the  static  machine  ;  the  converse  of  these  assertions  holds 


THE  ROXTGEX  KAY  APPARATUS.         209 

good  for  the  coil.  If  the  leads  are  freely  u brushing"  the  tube  may  be 
seriously  interfered  with.  These  brush  effects  fill  nervous  patients  with 
fear;  hence  it  is  difficult  to  keep  them  steady  for  a  sufficient  length  of 
time  required  for  the  exposure.  It  must  be  remembered  that  a  small  am- 
perage of  static  current  does  not  produce  the  necessary  penetration  for 
good  skiagraphic  or  fluoroscopic  effects  of  the  deeper  structures  of  the 
body,  nor  is  it  adapted  for  short  exposures  ;  this  can  be  partially  reme- 
died by  augmenting  the  number  of  plates  or  by  increasing  the  speed. 
If  non-breakable  plates  are  employed,  the  speed  of  revolution  may  be 
increased  manifold,  without  increasing  the  number  of  the  plates,  and 
the  deficiency  is  thus  overcome  in  X-ray  work.  Other  objections  that 
may  be  urged  against  these  machines  are  their  bulkiness  and  the  sudden 
and  frequent  changes  in  their  polarity  and  failure  to  work  in  damp 
weather. 


14 


CHAPTER   II 

THE   PRINCIPLES   OF   TECHXIC. 
I.  Fluoroscopy. 


briefly  described  the  X-ray  apparatus  and  the  modes  of  its 
manipulation,  we  shall  now  dwell  upon  the  methods  of  its  practical 
application. 

When  conducting  such  examinations,  it  is  essential,  though  not 
absolutely  necessary,  to  have  the  room  darkened  so  as  to  exclude  ordi- 
nary light.  Of  course  the  rays  are  invisible.  The  means  employed 
for  detecting  the  presence  of  the  invisible  Rontgen  rays  are  (1)  by  its 
physical  effects,  —  i.  e.,  the  ability  of  these  rays  to  produce  a  fluorescence 
from  certain  substances  ;  (2)  by  the  chemical  effects  taking  place  on  the 
sensitive  plate. 

For  making  fluoroscopic  examinations  we  may  employ  either  the 
fluorescent  screen  or  the  closed  fluoroscope.  A  cryptoscope  has  been 
brought  into  the  market  which  allows  of  the  detachment  of  the  screen 
from  the  hood,  Fig.  104,  thus  permitting  of  the  use  of  the  former 
without  the  cumbersome  attachment 

A.  METHODS  OF  EXAMINATION. 

(a)  Screen  Examinations.  —  By  daylight  the  fluorescence  of  the  screen 
is  wholly  imperceptible.  Hence  the  necessity  of  excluding  any  light 
that  might  fall  upon  the  screen  and  the  eyes  of  the  examiner. 

The  brilliant  fluorescence  becomes  manifest  only  in  a  darkened 
room,  and,  therefore,  as  in  Rontgen's  original  experiment,  in  order  to 
exclude  this  extra  light  the  tube  should  be  covered  with  some  dark 
material. 

The  examiner  holds  the  open  screen  in  his  hands,  shifting  it  to  the 
part  desired,  or  it  may  be  clasped  to  an  adjustable  rod  attached  to  a  frame 
which  rests  upon  the  floor.  When  the  open  screen  is  used,  it  should  l>e 
brought  as  close  as  possible  against  the  part  under  examination,  so  as  to 
bring  out  the  shadows  more  distinctly. 

Prior  to  covering  the  tube,  it  must  be  placed  in  its  proper  position, 
preferably  with  the  platinum  anode  pointing  toward  the  operator;  the 
patient  is  then  placed  in  front  of  the  excited  1nlx>.  (The  cryptoscope  is 
used  in  a  lighted  room.)  In  order  to  make  a  thorough  examination  the 
examiner's  eyes  must  w\  accustomed  to  the  darkened  condition  of  the 
interior  of  this  apparatus.  "When  used  on  a  sunny  day,  only  the  dark 
contour  of  the  part  under  examination  is  first  seen,  gradually  giving  way 
to  the  more  distinct  details.  Long  and  frequent  examinations  by  this 
210 


THE  PEINdPLBS  OF  TECHNIC. 


211 


means  tire  the  eyes,  often  producing  conjunctivitis  among  operators. 
For  superficial  and  preliminary  examinations  this  appliance  is  indispen- 
sable, but  for  deep  examinations  the  open  screen  and  dark  room,  with  the 
tube's  phosphorescence  shielded,  are  to  l>e  recommended. 


FIG.  104.— Detachable  fluoroscope  and  screen. 

With  a  cryptoscope  only  one  person  is  enabled  to  view  the  images 
cast  upon  the  screen.  "When  the  screen  alone  is  employed  a  group  of 
persons  can  see  the  existing  conditions,  hence,  the  latter7  s  value  for 
demonstrative  purposes. 

(b)  Preparation  of  IJtc  Patient. — Always  remove  the  clothing  of  the 
patient  from  the  part  which  is  to  be  examined,  permitting  in  some 
instances  the  retention  of  the  under  garment,  which  should,  however, 
always  be  free  from  wrinkles.  Pius,  buttons,  and  any  other  metallic 
structures  which  would  cast  shadows  upon  the  screen  must  be  removed, 
to  prevent  an  incorrect  diagnosis. 

In  surgical  cases  where  fine  detail  work  is  demanded,  it  is  necessary 
to  remove  all  the  garments  from  the  part  to  be  examined,  also  splints, 
bandages,  and  powder  dressings,  as  acetanilid,  iodoform,  boric  acid,  and 
plaster  of  Paris,  all  of  which  produce  shadows  upon  the  screen.  The 
retention  of  wooden  splints,  though  offering  little  or  no  obstruction  to  the 
rays,  interferes  with  a  thorough  examination  of  a  part  on  account  of  the 
immobilization  of  the  joints,  the  ends  of  fractured  bones,  etc.  These 
splints  act  as  stays  and  do  not  permit  of  any  movement  of  the  part  or 
of  the  close  approximation  of  the  screen. 


I'll' 


BLECTKO-THEKAPEUTICS. 


(c)  Position  of  the  Tube. — The  tube  should  be  carefully  clamped  into 
the  notch  of  the  holder  so  that  the  platinum  anode  points  to  the  sen-en's 
centre,  causing  it  to  fluoresce  equally.  The  rays  should  pass  in  a  straight 
line  and  not  obliquely  from  the  tube  to  the  object.  AVhen  examining  the 


FIG.  105.— A  STUDY  IN  SHADOW  DISTORTIONS  (  FLUOROSCOPIC  OR  SK.IAGRAPHIC)  WITH  CORRE- 
SPONDING DENSITY  DIFFERENCE.— A,  Anode  parallel  with  the  photographic  plate.  B,  Axis  of  the  tube 
parallel  with  the  plate.  C,  Tube  midway  between  the  above  positions. 

1,  Either  position  of  the  object  will  throw  the  same  shadow ;  the  darker  portion  indicates  the 
denser  portion,  whether  the  vertex  is  up  or  down.  2,  Shadow  smaller  and  denser.  3,  Same  object 
slightly  enlarged.  4,  Cylinder  or  bone.  Shadow  denser  at  the  extremities,  because  the  rays  must  trav- 
erse more  substance  at  those  positions.  5,  Metallic  cylinder.  To  ascertain  the  perpendicularity  of  the 
rays,  cross  wires  are  placed  upon  both  ends,  when  the  shadows  of  the  latter  will  superimpose  on  the 
plate  or  fluoroscope.  If  these  shadows  do  not  superimpose,  the  rays  are  taking  an  oblique  course. 
6,  Penny  on  its  edge.  The  shadow  line  is  dense,  as  the  rays  traverse  much  substance.  7,  Stir:;;. 
of  the  same.  8,  Fracture  of  two  bones.  The  shadows,  being  superimposed,  cast  a  very  dense  shadow. 
9,  Rays  traverse  through  less  substance  when  the  bones  are  longitudinally  arranged,  and  cast  less  dense 
and  separate  shadows. 

thorax,  for  example,  the  tube  should  be  so  positioned  as  to  cause  the  rays 
to  fall  perpendicularly  upon  the  screen.  When  examining  a  field  near 
the  first,  it  is  advisable  to  have  the  tube  remain  stationary,  and  to  move 
the  patient  as  necessary. 

Experience  alone  will  guide  the  beginner  as  to  the  distance  most  suit- 
able for  producing  the  best  images  upon  the  screen.  For  fluoroscopic 


PRINCIPLES  OF  TKCHXIC.  213 

work  the  patient  is  usually  brought  closer  to  the  tube  than  when  a  skia- 
gram is  taken.  The  shadows  on  the  screen  may  often  be  sharply  brought 
out  by  a  careful  and  systematic  adjustment  of  the  distance  between  the 
patient  and  the  tube. 

(d)  Position  of  Patient. — The  patient  may  be  examined  by  means  of 
the  fluoroscope  in  the  lying,  sitting,  or  standing  positions. 

(e)  Size,  Shape,  and  Intensity  of  J//wv  <>n  the  Screen. — The  X-rays 
diverge  as  they  are  projected  from  the  anode.     The  shadow  thrown  on 
the  screen,  therefore,  will  be  larger  than  the  object  itself.     If  the  object 
is  brought  closer  to  the  tube  the  distortion  in  size  will  be  increased.     The 
further  the  11  uoroscope  is  separated  from  the  object,  the  larger  but  less 
definite  will  be  the  shadow  cast.     If  the  rays  do  not  fall  perpendicularly, 
the  shadow  on  the  screen  will  be  distorted.     This  cau  be  well  illustrated 
by  the  following  experiment.     (Fig.  105.) 

Take  a  lighted  candle  and  hold  it  fifteen  or  twenty  inches  (38  or  51 
cm. )  from  a  white  surface  ;  between  it  and  the  candle  place  a  coin.  Upon 
moving  the  coin  toward  the  white  surface,  its  shadow  becomes  smaller 
and  smaller  as  it  is  gradually  made  to  approach  that  surface.  The  re- 
verse occurs  when  the  coin  is  moved  from  the  white  surface  toward  the 
candle.  Upon  altering  the  plane  of  the  coin  a  shadow  of  different  shape 
is  produced.  When  the  rays  fall  perpendicularly  on  the  surface  of  the 
coin,  the  shadow  produced  will  be  circular,  but  when  tilted  so  that  the 
rays  strike  in  an  oblique  direction,  the  shadow  cast  will  be  elliptical. 
The  change  in  size  and  shape  of  the  shadow  can  be  accomplished  by  al- 
tering the  position  either  of  the  source  of  light  or  of  the  object.  These 
principles  are  equally  true  in  fluoroscopy  and  skiagraphy. 

The  intensity  of  the  shadow  on  the  screen,  even  of  the  same  kind  of 
structure,  will  vary  in  different  individuals.  Thus  the  shadow  of  the 
adult  male  thorax  will  be  darker  than  that  given  by  a  child's  thorax. 
This  difference  in  intensity  depends  upon  the  degree  of  penetrability  of 
the  rays,  the  distance  of  the  tube  from  the  fluoroscope,  and  the  relative 
thickness  of  the  part. 

The  operator  should  be  thoroughly  conversant  with  the  normal  ap- 
pearance of  the  parts,  so  that  he  can  use  this  knowledge  as  a  standard  of 
comparison  for  the  corresponding  affected  part  in  the  same  individual. 

B.  ADVANTAGES  OF  FLUOROSCOPY. 

The  method  of  using  the  fluoroscope  is  simple,  inexpensive,  and 
rapid,  and  allows  of  immediate  comparison  with  the  corresponding  nor- 
mal part.  The  mobility  brought  about  in  the  structure  under  examina- 
tion permits  of  its  study  in  different  positions.  In  examining  certain 
parts  that  are  in  constant  motion,  as  the  heart,  diaphragm,  and  thorax, 
a  study  can  be  made  of  any  abnormality  in  their  movements. 


214  ELECTRO-THERAPKr  IK  S. 

C.  DISADVANTAGES  OF  FLUOROSCOPY. 

One  of  the  limitations  of  this  method  is  that  the  record  is  not  perma- 
nent, although  "tracings"  can  be  made.  In  prolonged  exposures  for 
examinations  the  patient  is  liable  to  be  "  burnt,"  and  the  same  injury 
may  befall  the  operator's  hands  and  eyes  ;  for  this  reason,  I  at  present 
never  employ  the  fluoroscope,  having  discarded  its  use  five  years  ago. 
Thicker  parts,  as  the  adult  abdomen,  the  hip,  and  the  skull,  do  not  per- 
mit of  satisfactory  examination  by  this  method.  The  same  is  true  of 
certain  fractures  which  present  no  displacement  of  the  fragments  (fissured 
fractures),  also  in  detecting  and  locating  small  foreign  bodies.  As  the 
soft  structures  present  varying  degrees  of  density,  the  presence  of  diseased 
bone,  tumors  of  muscles  or  of  the  brain,  etc.,  cannot  be  differentiated, 
owing  to  the  affected  tissue  having  only  a  slightly  different  density  from 
that  of  the  surrounding  normal  parts.  As  the  penetrability  of  the  rays 
cannot  be  controlled,  and  the  varying  degrees  of  density  confuse  the  eye, 
the  differentiation  by  means  of  the  fluoroscope  becomes  at  once  most 
difficult  and  unsatisfactory. 

II.   Skiagraphy. 

A.  SYNONYMS,  DEFINITION,  AND  NOMENCLATURE. 

Skiagraphy  (Rontography,  Shadowgraphy,  Ixography,  Electro- 
graphy,  Skotography,  Kathography,  Fluorography,  Actiuography,  Radio- 
graphy, Diagraphy,  Skiography,  Pyknoscopy,  New  Photography,  and 
Electro-Skiagraphy)  is  the  art  of  photographing  shadows  on  sensitive 
plates  by  means  of  transmitted  light.  The  Rontgeu  Congress  in  Berlin 
on  May  2,  1905,  adopted  a  uniform  nomenclature  for  the  use  of  the  Con- 
gress and  for  expression  in  writing.  The  following  terms  will  be  used 
in  the  future:  Rontgenology,  Rontgenoscopy,  Rontgenography,  Rout- 
genogram  (Rontgeu  negative,  Routgen  positive,  Rontgen  diapositive), 
Ortho- Rontgenography,  Rontgentherapy,  Rontgenizing.  I  present  this 
new  nomenclature,  but  I  can  hardly  endorse  it.  I  believe  that  the  word 
u skiagraph"  and  its  modifications  are  more  easily  pronounced,  more 
general,  and  more  euphonious. 

The  differentiation  between  an  ordinary  photograph  and  a  skiagraph 
is  as  follows:  A  photograph  is  an  image  produced  on  a  sensitive  plate 
in  a  camera  by  ordinary  light,  reflected  from  the  surface  of  the  object, 
converging  and  passing  through  a  lens  or  pin-hole  and  then  diverging 
and  falling,  thus  producing  a  reduced  size  of  the  image  on  the  plate. 
Therefore,  a  photograph  is  a  " reflected"  picture,  and  we  see  only  that 
part  of  the  object  that  is  near  or  toward  the  optical  perimeter  when  the 
object  is  opaque ;  if  transparent,  the  refraction  obscures  the  clearness  of 
the  farther  side. 


PHILADELPHIA  HOSPITAL 
RONTGEN   RAY  LABORATORY,   RECORD  OF   DIAGNOSIS. 


No. 


1 

NAME 

\DDRESS                                     Nativity                                Month           Day         fgo 

Occupation 

2 

SEX   Male         -n^v 

Color          Weight             ll>>.      I  >.-]iartment                          Referred  by                            M.D. 

Female      Ma?ried 

Height                     |  Ward                                      Address 

3 

Previous  History 

4 

5 

6 

7 

8 

Date.  Place, 
Duration,  Character,  etc., 
of  Injury  or  Disease. 

Part  or  Organ  Involved 

at                       Physical 
and 
Clinical 

Chemical  and  Microscopical 
Examinations 

9 

REMARKS 

„,,..,,        j  •     r\-            •                                                    Diagnosis  made  from  Skiagram  or  Fluoroscope 
Techmc  Employed  in  Diagnosis.                                                                          or  Stereo-Skiagraph 

I 

IPPARITTJS 

II                                       III 

POSITIONS  OF  THE  TUBE  QUALITIES  OF  THE  RAYS, 
AND  PATIENT              TIME  OF  EXPOSURE 

A 

\ 
I 

Varieties  and  Make 

Distance  of  Anwle           Current  going  to  the 
from  Plate                         Primary  Coil 

inch  [             cm. 

Volts              Amp. 

Revolving  Plates 

Numbec 

Thickness  of  the  Part 

Secondary  or  Induced 
Current 

inch                 cm. 

Inch                 cm  . 

POSITIONS  OF  PART 

Parallel  Spark-gap 

Rev.  per  Minute 

inch                 cm. 

Length  of  Spark  -gap 

Anterc-  posterior 

No.  of  Benoist's  Scale 

inch  |             cm. 

Lateral 

Degree  of  Vacuum  of 
Tube:      Low    (soft). 
Medium.  High  (hard) 

B 

Accumulator          Volts 

Flexion 

Extension 

Time  of  Exposure 

SOURCK 
OF  CURRENTS 

Ampere-hour 

Dorsal  Decubitus 

sec.               min. 

Direct  Current 

Ventral  Decubitus 

Intensifying  Screen 

Altern.  Current 

Recumbent 

Variety  of  the  Plate 

Transformer 

C 

Varieties 

Semi-recumbent 

Sizes      Nos.      Parts 

Sitting 

X           A 

gi 

aj 

Standing 

X            B 

Length  of  Spark-gap 

With  or  without 
Bandage.  Splint,    Cast 

X           C 

OPERATOR 

inch                cm. 

Negatives    • 

D 

Varieties 

E     v- 

Over  or  under-exposed 
or  developed.  Patient 
moved 

t> 

x 

8 

No.  of  I  nterrupiii  >ns 

*"        Non-Regulating 

S3 

No.  of  Prints 

Per  Minute 

g        Self-Regulating 

Duplicate 

AUTOPSY 

Mechanical 

f§        Osmo-Regulat. 

Mercury 

Wehnelt 

CkldweU 

Simon 

Diagnosis  made  by  Director AI.D. 

or  Assistant M.D. 

215 


216  ELECTRO-THERAPEUTK  S. 

In  skiagraphy  the  X-rays  emanate  from  a  small  point  (1  mm.  anode), 
diverge  and  pass  through  bodies  opaque  to  ordinary  light,  throwing  a 
relative  shadow  of  the  object  on  a  sensitive  photographic  plate,  producing 
merely  an  actual  silhouette.  The  skiagraph,  therefore,  is  produced  by 
transmitted  light. 

Before  taking  a  skiagram,  determine  the  best  possible  position  that 
can  be  secured,  by  first  employing  the  fluoroscope,  and  then  substituting 
for  it  the  sensitive  photographic  plate.  On  the  latter  the  image  east  will 
appear  reversed, — i.e.,  the  bones  will  appear  white  and  the  surround  ing 
soft  structures  darker,  due  to  the  fact  that  in  the  bones  more  rays  will  be 
absorbed,  fewer  penetrate,  and  hence  there  will  be  decreased  oxidation  on 
the  photographic  plate.  When  a  photographic  print  is  made  from  this 
negative,  the  appearance  will  be  identical  with  the  fluoroscopic  image. 
(Hereafter  the  term  xkia</r<tfth  or  skiagram  will  be  used  for  the  printed 
positive,  and  the  developed  sensitive  (photographic)  plate  will  be  termed 
the  negative.) 

B.  THE  PATIENT. 

History  Taking.  — It  is  advisable  to  take  complete  histories  of  all  cases. 
I  employ  the  accompanying  blank  in  book-form  in  the  Philadelphia 
Hospital  and  in  private  work.  Its  main  features  are,  the  history  of  the 
case  and  the  technic  employed  in  each  instance. 

Preparation  of  the  Patient. — Expose  the  part  to  be  skiagraphed  by 
removing  the  clothing.  If  the  part  is  an  extremity,  have  it  totally  bared. 
"When  examining  the  chest  or  abdomen,  should  the  patient  be  chilly  or 
complain  of  the  unpleasant  sensation  caused  by  the  plate,  or  be  abashed 
at  the  thought  of  completely  disrobing,  the  wearing  of  an  undergarment 
may  be  permitted,  or  the  part  may  be  covered  by  a  sheet  of  white  linen, 
care  being  taken  to  remove  buttons  and  pins,  and  not  permitting  any 
wrinkles  or  creases  to  exist  in  the  field  to  be  examined.  If  a  part  of  the 
forearm  or  leg  is  to  be  examined  for  fracture,  dislocation,  etc. ,  splints  and 
dressings  of  iodoform,  boric  acid,  bismuth  subuitrate,  lead  water  and 
laudanum,  etc.,  must  all  be  removed  and  the  part  skiagraphed  in  a  bared 
condition.  If  a  compound  fracture  is  examined,  avoid  infection  by 
covering  with  a  thin  sterilized  gauze.  In  examining  the  abdomen,  a 
purgative  should  be  administered  ten  or  twelve  hours  prior  to  the  exami- 
nat  ion.  The  patient  must  not  be  permitted  to  indulge  in  eating  solid  food 
previous  to  the  examinat  ion.  The  urinary  bladder  should  be  emptied  be- 
fore being  skiagraphed,  for  calculi,  and  a  rectal  enema  given.  The  walls 
of  the  stomach  may  be  readily  outlined  by  having  the  patient  ingest  large 
doses  of  bismuth  subnitrate  for  two  weeks  prior  to  the  examination. 

Position  of  I'alit'iit.  —The  patient  should  be  placed  in  a  comfortable 
position.  It  is  sometimes  not  possible  to  do  this,  hence  the  necessity  of 


THE  PEIXCIPLES  OF  TErilNir.  217 

conducting  the  examination  rapidly,  but  without  sacrificing  the  results 
desired.  In  order  to  ascertain  the  necessary  position  for  the  patient  to 
occupy  first  examine  with  the  fluoroscope. 

The  patient  may  assume  various  positions  in  skiagraphic  work, 
which  will  be  dealt  with  under  the  various  clinical  conditions.  They 
arc-  :  the  erect  or  sitting,  anterior,  posterior,  or  lateral,  recumbent,  dorsal 
decubitus  and  ventral,  named  after  the  position  or  view  of  the  part  that 
is  in  contact  with  the  sensitive  plate  or  fluoroscope. 

Immobilization  of  the  Part. — To  obtain  the  sharpest  outlines  on  the 
plate,  the  patient  must  not  be  permitted  to  move  while  under  examination, 
or  failure  will  be  the  inevitable  result.  Those  that  are  timid  should  be 
previously  instructed  to  ignore  noises,  flashes,  etc. ,  necessarily  occurring 
during  the  examination.  It  is  better  for  the  skiagrapher  to  have  an 
under-exposed  plate  rather  than  one  that  is  blurred.  This  blurring  may 
be  independent  of  the  patient,  and  be  caused  by  the  shaking  of  the  tube 
or  the  table,  or  of  both. 

The  part  to  be  examined  may  be  held  in  one  position  by  firmly 
strapping  it  to  the  table,  although  I  seldom  find  this  necessary.  In  cer- 
tain cases,  as  in  fractures,  where  there  is  movement  of  the  part  (the  result 
of  muscular  spasm),  the  annoying  symptom  may  be  met  by  steadying 
the  limb  with  sand- bags,  etc.  When  it  is  found  impossible  to  keep 
children  and  the  insane  under  control,  resort  must  be  had  to  hypodermic 
injections,  or  to  the  administration  of  an  anaesthetic. 

C.  PLATES,  THEIR  PREPARATION,  SIZE,  AND  PROTECTION. 

The  plates  as  sent  by  the  maker  are  not  ready  for  use  j  hence  it 
becomes  necessary  to  assort  and  arrange  them  in  a  dark  room,  so  that 
they  may  be  conveniently  handled  by  the  examiner.  Place  the  plate  in 
a  black  paper  envelope,  which  in  turn  is  covered  by  a  heavy  j-ellow  one  ; 
this  prevents  injury  by  light,  though  it  will  be  affected  by  the  X-rays 
with  as  great  ease  as  desired.  The  size  of  the  plate  depends  upon  the 
dimensions  of  the  part  to  be  skiagraphed  ;  those  that  I  usually  employ 
are  one  size  larger  than  is  absolutely  necessary.  The  plate  should  be 
protected  against  breakage,  damage  from  perspiration  or  other  excretions 
of  the  body,  and  from  heat.  To  insure  against  breakage,  it  should  be 
placed  over  a  smooth  board,  as  I  find  that  a  plate-holder  is  objection- 
able in  preventing  the  approximation  of  the  plate  close  enough  to  the 
part  to  be  examined,  thus  preventing  sharp  definition  of  shadows. 
IJctweeii  the  patient  and  the  plate  I  introduce  a  blotter  or  a  sheet  of 
aluminium,  oiled  silk,  or  celluloid,  which  prevents  injury  from  sweat, 
urine,  etc.  For  the  sake  of  comparison,  it  is  a  wise  provision  to  have  the 
plate  large  enough  to  take  both  sides  of  the  body  (hips,  shoulders,  etc. ). 
For  this  purpose,  place  the  tube  in  the  median  line  of  the  body  and  take 


218  ELECTRO-THERAPEUTICS. 

both  sides  with  one  exposure.  This  obviates  the  error  that  would  result 
if  the  two  sides  were  taken  .separately,  when  in  all  probability  the  posi- 
tions would  be  different.  \Vhere  the  plate  cannot  be  brought  in  contact 
with  the  part,  owing  to  a  curvature  of  the  latter,  as  on  the  flexor  or 
extensor  surfaces  of  the  elbow,  or  on  the  spine,  in  common  with  others, 
I  at  times  resort  to  the  use  of  a  film.  The  plate  should  be  placed  against 
or  under  the  part  examined,  with  the  gelatine  side  up.  The  part  should 
be  as  nearly  centralized  on  the  plate  as  possible,  so  as  to  get  the  import- 
ant outlining  shadows  directly  in  the  centre  of  the  plate.  Rays  should 
fall  as  nearly  perpendicular  as  possible. 

Data  on  the  Negative.  — It  is  always  advisable  that  the  plate  should  be 
marked  so  as  to  guard  against  errors.  The  method  of  plate-marking 
that  I  employ  consists  in  placing  lead  letters  and  numbers  in  reverse  type 
in  the  corner  of  the  plate,  designating  the  part  examined,  the  date, 
the  name  of  the  operator,  and  also  the  name  of  the  institution.  The 
letters  and  numbers  employed  for  this  purpose  should  be  small,  so  as  to 
not  occupy  too  much  space  on  the  plate.  "When  exposing  a  part  I 
usually  indicate  on  the  plate  whether  "right"  (R)  or  "left"  (L). 
"When  making  more  than  one  exposure  of  the  same  part,  I  usually 
indicate  the  number  of  separate  exposures  consecutively  by  placing 
on  the  plate  the  lead  letters,  A,  B,  and  C.  In  medico-legal  cases  an 
identifying  mark  is  most  important. 

D.  SELECTION  AND  USE  OF  THE  CROOKES  TUBE. 

The  Crookes  tube  must  be  selected  according  to  the  requirements  of 
the  case.  Thus,  the  "hard"  tube,  which  produces  a  greater  degree  of 
penetrability  of  the  rays,  is  adapted  for  the  thicker  parts,  in  detecting 
the  larger  foreign  bodies,  and  in  taking  a  negative  of  a  fracture  through 
a  plaster  cast.  In  making  skiagraphs  of  children,  where  their  move- 
ments would  ordinarily  blur  the  negative,  the  short  exposure  required  by 
this  variety  of  tube  is  a  marked  advantage. 

"When  soft  tissue  differentiation  is  to  be  brought  out,  as  in  skia- 
graphing  a  muscle  tumor,  a  cyst,  a  small  foreign  body,  or  a  tuberculous 
focus  in  bone,  resort  must  be  made  to  "  medium  "  or  even  "  hard  "  tubes. 

The  consensus  of  opinion  among  the  profession  is  that  a  soft  tube  is 
desirable  for  skiagraphiug  soft  tissues  in  order  to  obtain  a  clear  tissue 
differentiation.  But  I  have  abundantly  proved  that  with  a  hard  tube,  a 
short  exposure,  and  proper  development,  the  same  end  may  be  attained. 
The  advantages  of  the  latter  method  are  :  The  time  of  exposure  being 
brief,  the  liability  of  movement  of  the  patient  is  minimized  and  there  is 
less  liability  of  penetration  than  with  a  soft  tube  of  a  longer  exposure. 

Position  of  the  Tube.  —  Some  investigators  claim  that  no  X-rays 
are  produced  back  of  the  anode,  others  assert  that  they  do  exist  in  this 


THE  PRINCIPLES  OF  TECHNIC.  219 

position  but  possess  very  little  penetrating  power.  As  to  whether  the  rays 
are  uniform  in  penetration  in  the  active  hemisphere,  or  if  they  possess  a 
point  of  maximum  intensity,  is  another  disputed  question.  Buguet  and 
Londe  assert  that  the  intensity  of  the  rays  varies  at  the  active  hemisphere 
in  different  tubes,  and  in  different  kinds  of  the  same  tube.  In  some 
tubes  the  most  effective  X-rays  are  evolved  at  right  angles  to  the  axis  of 
the  tube  ;  in  which  case  the  latter  must  be  placed  parallel  to  the  object 
to  be  skiagraphed.  In  other  tubes  the  zone  of  greatest  intensity  is  at  a 
right  angle  to  the  plane  of  the  anode,  when  the  auodal  surface  should  be 
in  the  centre  and  parallel  to  the  object  under  examination.  I  prefer  a 
position  intermediate  between  these  two.  (See  Fig.  105,  C.) 

M.  Bordier1  says:  "The  direction  of  this  principal  axis,  along 
which  the  Routgen  effects  are  at  a  maximum,  must  be  determined  sepa- 
rately for  each  focus-tube,  and  it  evidently  lies  in  the  median  plane, — i.  e. 
in  the  plane  passing  through  the  centre  of  the  cathode  and  perpendicular 
to  the  auti- cathode." 

He  placed  a  series  of  pastilles  in  an  arc,  having  for  a  centre  the 
focus  of  the  anti-cathode ;  the  direction  of  the  principal  axis  was  given 
by  the  pastille  which  was  most  discolored. 

In  experiments  on  three  Miiller  tubes  tested  in  this  way  it  was 
found  that  the  principal  axis  made  an  angle  of  70°  with  the  line  passing 
through  the  centres  of  the  cathode  and  the  anti-cathode. 

.Form  of  the  Ray-emitting  Area  of  the  Anti-cathode. — Gocht,2  in  experi- 
menting with  a  pin-hole  camera,  succeeded  in  photographing  a  luminous 
area  on  the  surface  of  the  anti-cathode,  the  ray-emitting  area  having  a 
pyriform  -ovoid  shape.  He  asserts  that  the  angle  between  the  plate  and 
the  anti-cathode  at  which  the  spot  of  light  is  most  circular  and  there  is 
least  penumbra  is  not  45°,  but  nearly  65°. 

Direction  of  the  Rays. — Rays  emanating  from  Crookes  tube  should 
fall  perpendicularly.  To  prove  this,  place  a  metallic  cylinder,  3  or  4 
inches  long,  over  the  plate  or  on  the  screen.  If  the  rays  are  perpen- 
dicular the  shadow  cast  will  be  circular ;  if  the  rays  are  proceeding  in 
an  oblique  direction,  the  shadow  will  be  elliptical  or  the  shadows  of  two 
cross  wires  on  both  the  ends  will  not  be  superimposed.  (See  Fig.  105,  5.) 

Distance  of  the  Tube  from  the  Plate. — The  thicker  the  part  and  the 
greater  the  extent  in  area  to  be  skiagraphed,  the  greater  should  l>e  the 
distance  between  the  tube  and  the  object.  This  distance  must  be 
measured  from  the  anode  to  the  plate,  and  is  usually  about  20-24  inches 
(50  or  60  centimetres).  Where  any  movement  of  the  part  is  likely,  it 
is  preferable  to  place  the  tube  closer,  in  order  to  reduce  the  time  of 
exposure. 

1  Archives  of  the  Rontgen  Ray,  June,  1906,  p.  7. 

2  Ibid.,  April,  1906,  p.  312. 


220  ELECTKO-THERAPEUTICS. 

E.  FACTORS  VARYING  THE  TIME  OF  EXPOSURE. 

This  is  most  important  :  no  definite  rule  can  be  formulated  relative 
to  the  standardization,  of  any  unit  of  time.  The  time  of  exposure  varies 
under  the  following  conditions  : 

1.  The  capacity  of  the  apparatus  and  the  penetrability  of  the  rays. 

2.  The  peculiarity  of  the  part  to  be  examined. 

Under  the  first  heading  we  must  consider  the  size  and  make  of  the 
apparatus.  If  the  static  machine  is  used,  we  must  take  into  account  the 
numl>er  and  size  of  the  plates  and  the  rapidity  of  the  revolutions  per 
minute.  In  the  use  of  the  coil  account  must  be  taken  of  its  size,  and  the 
variety  of  the  interrupter,  with  its  frequency  of  interruptions,  etc. 

Under  the  secondary  heading  we  consider  the  thickness  of  the  part 
and  its  texture.  The  thicker  the  part,  the  more  prolonged  must  be  the 
exposure ;  nevertheless,  while  the  chest  is  as  thick  as  the  abdomen,  the 
latter  requires  a  longer  exposure,  because  the  former  is  more  easily  pene- 
trated by  the  rays,  due  to  the  contained  air. 

Quality  of  the  Rays. — Rays  of  high  degree  of  penetrability  will  require 
a  shorter  time  of  exposure,  and  conversely  with  rays  of  medium  and  low 
degrees  of  penetration.  The  sensitiveness  and  variety  of  the  plate  play 
a  minor  part  in  the  time  of  exposure.  Xo  plate  has  thus  far  been  found 
that  is  specially  sensitive  to  the  X-rays  only. 

Intensifying  Screens. — Intensifying  screens  are  intended  to  shorten  the 
time  of  exposure  by  placing  in  contact  with  the  photographic  plate  a 
screen  of  fluorescent  substance,  the  latter  acting  like  ordinary  light  on  the 
sensitive  plate.  It  must  be  borne  in  mind,  that  the  granularity  of  the 
fluorescing  surface  reduces  the  definition  of  the  skiagram,  at  the  same 
time  omitting  details  of  the  smaller  bony  structures,  and  the  necessity 
of  either  using  color-sensitive  (ortho- chromatic)  plates,  or  first  color- 
sensitizing  ordinary  plates,  since  the  best  screen  (platiuo-cyanide  of 
barium)  fluoresces  with  a  yellowish-green  light  which  does  not  greatly 
affect  ordinary  dry  plates. 

I  have  conducted  experiments  that  lead  me  to  the  belief  that  the  ratio 
of  exposure  necessary  with  an  intensifying  screen  to  the  time  required 
wit  In  nit  the  screen  is  as  1  to  5  or  6.  This  screen  will  markedly  assist  in 
the  reduction  of  the  time  of  exposure  in  fractures  and  the  presence  of 
forei-n  hoilics  about  the  thicker  structures,  such  as  the  hip,  the  pelvis, 
and  the  abdomen.  Of  course  by  this  procedure  we  sacrifice  the  fine  de- 
tails ..fthe  softer  structures,  and  for  this  reason  I  have  abandoned  its  use. 

1".    l'K'i;\  i;\  1 1,,\  OF  SECONDARY  OR  SAGNAC  RAYS. 

When    the    Kont^eu   rays  penetrate  bodies,  the  so-called  secondary 
rays  of  Sagnar  are   produced   in  the  tissues.     The  rays  being  primary. 
ra\s  \\ill  in  turn  produce  rays  railed  the  tertiary. 


THE  PRINCIPLES  OF  TECHXIC.  221 

This  diffusion  or  production  of  secondary  and  tertiary  rays  will  be 
increased  when  the  time  of  exposure  is  increased  and  when  the  part  ex- 
amined is  oi'  considerable  thickness.  In  order  to  prevent  these  useless 
rays,  which  so  often  cause  a  foggy  appearance  on  the  negative,  many 
devices  have  been  suggested,  principal  among  which  are  the  following  : 

The  Lead  Iris  Diaphraym. — By  the  method  of  Albers-Schdnberg, 
— /.  <?.,  by  means  of  the  compression  diaphragm  (Fig.  99), — the  pri- 
mary rays  are  largely  cut  off,  with  a  consequent  lessening  of  the  sec- 
ondary rays.  The  irradiated  area  is  diminished  in  size,  and  the 
depth  of  the  parts  is  likewise  decreased,  through  the  pressure  exerted  by 
the  compressing  action  of  the  diaphragm. 

Robinson,  in  Holzknecht's  laboratory,  modifies  the  above  by  pressing 
upon  certain  parts  of  the  diaphragm  with  specially  devised  metallic  rods, 
in  order  to  make  the  diaphragm  conform  to  uneven  surfaces,  such  as  the 
ankle,  foot,  knee,  etc. 

I  have  seen  Coutreinoulius,  of  Paris,  applying  lead  plates  against 
the  flanks  and  chests  of  patients,  to  prevent  the  disappearance  of  the 
shadows  of  soft  tissues.  He  demonstrated  the  value  of  this  method  by 
employing  these  plates  on  one  side  only.  The  development  of  the 
negative  showed  in  detail  the  shadows  of  the  soft  parts,  while  on  that 
side  where  no  lead  plate  was  applied  the  shadows  of  the  soft  parts  were 
invisible. 

III.   Photography. 

The  photographic  processes  involved  in  the  production  of  a  nega- 
tive from  a  plate  that  has  been  exposed  to  the  X-rays  do  not  differ  from 
those  involved  in  making  ordinary  photographic  negatives.  Experience 
in  this  branch  of  X-ray  diagnosis  is  absolutely  necessary,  hence  steady 
and  continuous  work  is  essential,  in  order  to  become  familiar  with  the 
many  intricate  points  which  so  frequently  arise. 

Dark  Room. — The  dark  room  must  be  absolutely  free  from  ordinary 
light  and  so  constructed  as  to  allow  of  ready  ventilation.  Both  of  these 
requirements  may  be  met  by  utilizing  a  zig-zag  entrance.  The  room 
should  contain  trays,  graduates,  faucets  (for  hot  and  cold  water),  and  a 
suitable  box  or  tank,  encasing  vertical  grooves,  for  the  purpose  of  "fix- 
ing . "  As  the  process  of  developing,  which  we  shall  presently  describe, 
produces  a  staining  of  the  hands,  and  sometimes  a  dermatitis  from  the 
action  of  metol,  the  use  of  rubber  gloves  is  desirable.  After  employing 
them  for  a  short  while,  the  operator  becomes  accustomed  to  them.  When 
the  developing  is  completed,  they  should  be  thoroughly  rinsed  in  water 
and  hung  up  to  dry. 

Light.  —  When  developing,  advantage  may  be  taken  of  the  ruby  lan- 
tern or  incandescent  lamp,  properly  shielded.  Daylight,  on  account  of 


I .  LECTKO-THEKAPEUTK  s. 

its  variability,  is  nnsuited  tor  the  purpose.  In  brief,  the  room  should 
be  glazed  with  a  sash  composed  of  ground  glass,  a  yellow  and  a  ruby 
glass,  and  a  shade  or  curtain  of  a  dark  color. 

N/  Hxitin-  rhttf*  <tn<l  /-'/7//1.S-.  —Skiagraphs  are  easily  projected  on  photo- 
graphic glass  plates,  papers,  or  films.  Wet  or  collodion  plates  are  only 
slightly  affected  by  the  X-rays.  Great  advantage  is  secured  by  employ- 
ing double  emulsified  plates,  the  depths  and  contrasts  of  the  images  being 
brought  out  more  thoroughly.  Tire  X-ray  plate,  which  is  always  to  be 
preferred  to  the  ordinary  plate,  should  be  employed. 

Owing  to  their  flexibility,  celluloid  films  can  be  brought  in  contact 
with  any  uneven  part  of  the  body.  But  if  not  handled  with  scrupulous 
care,  the  emulsion  is  liable  to  crumble.  Other  objections  are  their  cost, 
their  constantly  varying  sensitiveness,  and  the  fact  that  they  are  not  easy 
to  manipulate. 

The  double-coated  celluloid  films  are  coated  singly  on  each  side, 
causing  a  reduction  in  time  to  the  exposure  of  the  rays ;  but  they  offer 
difficulties  in  development  and  by  transmitted  light  present  the  blurred 
effect  of  both  films.  Both  paper  and  celluloid  films  inay  be  superim- 
posed so  that  half  a  dozen  or  more  may  be  simultaneously  exposed  to  the 
rays.  Bromide  paper  can  be  examined  only  by  reflected  light.  This 
paper  is  cheap  and  does  not  necessitate  first  producing  a  negative ;  its 
use  is  not  to  be  recommended,  as  a  good  picture  never  results  thereby. 

Care  of  the  Plates.  —  Because  of  the  extreme  sensitiveness  of  the 
plates,  they  should  be  stored  in  places  that  are  absolutely  free  from 
smoke,  gases,  excessive  light,  etc.  The  temperature  of  the  room  should  be 
constant,  sudden  changes  being  liable  to  cause  a  condensation  of  moist- 
ure upon  the  coated  side  which  in  time  results  in  " mildew  fogging." 
The  plate  packages  or  boxes  should  be  placed  on  their  edges,  thus  avoid- 
ing undue  pressure  on  the  individual  plates.  As  to  the  number  of  plates 
to  be  kept  on  hand,  I  recommend  not  more  than  a  mouth's  supply, — the 
operator,  of  course,  must  be  governed  by  the  amount  of  work  he  is  doing. 
The  plates  should  not  be  unpacked  from  the  maker's  cases  and  placed  in 
the  regular  X-ray  envelopes  until  needed, — this  precaution  guards  against 
fogging  of  the  plate.  If  the  plates  are  to  be  stored  in  the  laboratory 
where  the  X-ray  apparatus  is  located,  a  wooden  closet,  carefully  lined 
with  sheets  of  lead,  should  be  built,  to  avoid  the  damaging  effects  of  the 
rays  upon  the  plates.  If  stock  plates  are  stored  in  an  adjoining  room, 
they  should  be  protected  against  the  rays  in  exactly  the  same  manner. 

A.  DEVELOPERS. 

A  developer  consists  of  four  parts, — (a)  reducer,  (6)  preservative, 
(c)  accelerator,  and  (W)  a  restrainer. 

:i       i;«/i«-f>r8.  —  The  best  reducing  agents  are  metol,  pyrogallol, 


THE  PRINCIPLES  OF  TKCIIXH1.  223 

eikouogen.  hydroehinone,  and  rodinal.  Tliey  all  undergo  easy  oxida- 
tion; hence  sodium  sulphite  is  added  as  a  (b)  preservative.  Combinations 
of  the  above  are  usually  preferred.  Regulate  the  action  of  the  developer 
by  the  addition  of  an  accelerator  or  a  restrainer.  If  the  reducer  acts 
tardily,  add  the  accelerator  (carbonate  of  sodium  or  potassium).  Too 
rapid  developing  with  strong  solutions  is  undesirable ;  it  means  lack  of 
gradation,  a  forcing  up  of  the  high  lights  before  the  developer  has  had 
time  to  act  on  the  less  exposed  pails  of  the  plate.  Ready  prepared  de- 
velopers will  not  be  suitable  for  skiagraphic  plates.  It  should  be  remem- 
bered that  the  operator  should  adhere  to  one  kind  of  developer  and 
become  thoroughly  acquainted  with  its  action.  The  following  are  the 
formula*  that  I  daily  employ  in  my  laboratory  : 

Water 100  ounces  (3000  c.  c.) 

Metol 120  grains  (8  grams.) 

Hydroehinone 100  grains  (6.6  grams. ) 

s<  >d.  sulphite  (crystals) 4  ounces.  (120  grams.) 

or 

Water 64    oz.  (1920  c.  c.) 

Eikonogen 1    oz.  (30  grams.) 

Hydroehinone J  oz.  (4  grams.) 

Sod.  sulphite  (crystals) 2£  oz.  (75  grams.) 

(c)  Accelerator. — With  either  of  these  reducing  solutions,  it  is  neces- 
saiy  to  employ,  in  conjunction,  an  accelerating  solution,  made  up  as 
follows : 

Water 64  oz.  (1920  c.  c.) 

Potass,  carb.  (crystals) 8  oz.  (240  grams.) 

Sod.  sulphite  (crystals) 2  oz.  (60  grams.) 

The  dry  or  anhydrous  chemicals  are  about  twice  as  strong  as  the 
crystals,  and  rii-c  r/rwJ. 

Combinations  of  hydrochinoue  with  metol  when  too  old  should  not 
be  used,  as  they  would  cause  the  negative  to  present  a  "streaky"  or 
"blotchy"  appearance. 

The  one  solution  developer  of  rodinal  is  convenient  and  effi- 
cient, especially  when  employed  for  two-sided  films  or  plates.  This 
agent  keeps  well  as  long  as  the  containers  are  kept  filled  and  tightly 
corked. 

With  its  use  the  image  appears  cpiiite  rapidly,  but  development 
must  be  continued  until  the  film  is  so  dense  that  no  details  are  discern- 
ible when  viewed  by  transmitted  light.  The  following  formula  may  also 
be  employed  : 

Rodinal 1  part. 

Water 20  to  40  parts. 


224  ELECTRO-THERAPEUTICS. 

An  advantage  of  the  ortol  developer  is  that  it  may  be  repeatedly 
used,  keeping  perfectly  well  as  long  as  the  stock  solution  is  kept  in 
small  bottles  and  tightly  corked.  Formula : 

Water 60  oz.  (1800  c.  c.) 

Ortol i  oz.  (20  grains. ) 

Potass,  bromide 20  grains  (1.3  grams.) 

Sulphite  of  soda  (crystals) 6  oz.  (180  grams.) 

Carbonate  of  soda  (crystals) 5  oz.  (150  grains.) 

For  use  :  Dilute  one  part  of  the  above  with  two  to  four  parts  of 
water,  according  to  the  density  desired. 

(d)  Restraining  Solution. — Ten  per  cent,  solution  of  potassium  bro- 
mide kept  in  a  tightly  corked  bottle.  (Pipette  and  dropper  are  useful 
adjuncts  in  the  handling  of  this  solution.) 

Tropical  Developer. — For  hot  climates  where  no  ice  is  available. 

"Water .50  ounces  ( 1500  c.  c. ) 

Sulphite  of  soda  (crystals ) 2  ounces  (60  grams. ) 

Bromide  of  potassium 20  grains  (1 .3  grains. ) 

Citric  acid 20  grains  (1.3  grams. ) 

For  use :  To  4  oz.  of  the  above  solution  add  10  grains  of  dry  amidol. 
Before  developing  place  the  plate  in 

Water 60  parts, 

Formalin 1  part, 

for  about  three  minutes,  rocking  the  tray  occasionally,  then  rinse  well 
and  place  in  the  developer. ' 

B.  MODUS  OPEEANDI  OF  DEVELOPMENT. 

After  the  plate  has  been  properly  exposed  it  is  taken  to  the  dark 
room,  the  envelope  opened,  and  the  plate  removed.  (After  having  been 
exposed,  it  should  not  be  allowed  to  remain  in  the  exposing  room,  if  an- 
other case  is  to  be  skiagraphed. )  Place  the  plate,  gelatine  side  up,  in  a 
tray  of  sufficient  size,  and  pour  on  the  developer.  For  development  of 

1  Henry  Hulst  (Transactions  of  the  American  Rontgen  Ray  Society,  1905)  says: 
"The  developer  which  I  use  for  exposures  of  one  second  or  less  in  chest  work,  I  use 
for  calculi  as  well.  It  is  as  follows  : 

Potassium  carbonate,  dry 12  dr.  (48  gm.) 

Sodium  sulphite,  dry 6  dr.  (24  gm.) 

Potassium  bromide  ( 10  per  cent,  sol.) 2  oz.  (59.2  c.  c.) 

Hydrochinone 4  dr.  (16  gm.) 

Water..                                1  qt.  (1  litre.) 

"  If  the  high  lights  begin  to  show  before  40  seconds,  from  two  to  four  ounces 
more  of  the  potassium  bromide  solution  are  added.  Development  should  be  complete 
in  four  minutes." 


THE  PRINCIPLES  OF  TEC  UNIT. 

the  plate,  take  four  (4)  parts  of  either  reducing  agent,  above  mentioned, 
and  about  one-lialf  Q)  part  of  the  accelerator  solution.  If  the  image 
does  not  appear  in  half  a  minute,  add  another  portion  of  the  accelerator. 
Thus  cautiously  add  at  very  brief  intervals  small  quantities  of  the  accel- 
erator, and  the  image  will  be  better  evolved  than  if  an  excess  of  the 
alkali  be  added  to  the  reducer  at  first.  Start  at  one  corner,  and  with  a 
.single  sweep,  pour  on  sufficient  solution,  rocking  the  tray  to  secure 
thorough  immersion  and  evenness.  To  splash  the  solution  is  to  produce 
air  bubbles.  a:id  the  latter  will  form  spots  on  the  negative.  Should 
air  bubbles  be  detected,  touch  them  lightly  with  a  pledget  of  cotton. 

For  development  of  a  special  make  of  plate,  follow  the  directions 
on  the  box.  Observe  all  changes  going  on  in  the  plate.  After  the  plate 
has  been  developing  for  a  minute  or  longer,  lift  it  from  the  tray  and  ex- 
amine it  by  transmitted  light  to  see  how  far  the  process  of  development 
has  advanced.  This  is  dependent  upon  the  time  the  sensitive  plate  was 
primarily  exposed  to  the  action  of  the  rays,  to  the  thickness  of  the  part 
under  examination,  the  type  of  plate,  and  also  upon  the  temperature  of 
the  developer  and  the  dark  room.  I  always  judge  the  density  by  trans- 
mitted light,  deeming  this  preferable  to  the  reflected  picture  from  the 
sensitive  side.  Another  method  is  the  appearance  of  the  picture  on  the 
glass  side  or  back,  showing  the  reduced  metallic  silver  deposited  on  the 
glass.  It  will  take  a  longer  time  to  develop  a  plate  of  the  lungs,  pelvis, 
abdomen,  or  the  denser  parts  of  the  body  than  it  does  of  the  hand  or  foot. 
For  the  former  structures  keep  the  plate  in  the  developer  until  the  whole 
surface  is  uniformly  blackened  and  very  little  light  is  transmitted.  In  the 
fixing  bath  the  proper  degree  of  density  will  be  produced.  To  strongly 
contrast  the  bony  and  fleshy  structures  of  a  part,  reduce  the  time  of  de- 
velopment or  dilute  the  developer;  the  result  will  be  a  "soft  negative/' 
The  necessary  density  may  be  obtained  later  by  intensification.  For  a 
good  negative,  start  with  weak  developers  and  gradually  increase  the 
strength  by  adding  stock  solutions  (the  reducer).  In  order  to  bring  out 
the  details  with  greater  delicacy,  some  prefer  to  use  first  a  suitable 
hydrochiuone  developer,  to  effect  sufficient  density,  and  then  transfer  the 
plate  in  rodiual  or  metol  developers.  When  the  plate  is  sufficiently  de- 
veloped, put  it  in  a  trough  of  running  water  or  under  a  stream  from  a 
spigot,  always  seeing  that  the  gelatine  side  is  up,  and  that  it  is  not  liable 
to  get  scratched  by  any  contact  with  the  spigot  or  other  body.  Continue 
the  washing  for  at  least  two  minutes. 

The  denser  the  structure,  the  less  will  be  the  oxidation  of  the  emul- 
sions, and  consequently  the  later  the  appearance  of  the  part  on  the  plate. 
I  f  st  ructures  of  different  densities  appear  simultaneously  on  the  plate,  it 
signifies  over  exposure  :  in  that  case,  pour  off  the  developer,  and  substi- 
tute a  fresh,  weak  developer.  It  should  be  remarked  that  the  developer 

15 


•JIM;  ELECTRO-THERAPEUTICS. 

must  imt  )>••  diluted,  as  it  makes  development  slow,  and  the  negative  will 
be  soft ;  this  is  especially  true  of  the  thick  parts  :  instead  put  iu  less  of 
the  accelerator  (sodium  carbonate).  During  the  summer,  put  ice  into 
the  developer,  or  put  the  developing  pan  into  a  tray  of  ice- water.  Tem- 
perature of  the  developer  should  be  65°  or  70°  F.  (18°  to  21°  C.).  Over 
exposed  plates  should  not  be  removed  quickly  from  the  tray,  as  the  de- 
veloper will  not  have  time  to  penetrate  sufficiently  deep  to  affect  the  lower 
layers  of  emulsion ;  although  the  upper  layer  by  its  darkening  may 
deceive  the  operator. 

If  the  image  appears  slowly, — i.  e.,  within  a  minute  or  two, — it  sig- 
nifies under  exposure;  in  this  case  tilt  the  solution  to  the  corner  of  the 
tray,  and  add  some  of  the  accelerator.  If  after  this  addition  and  suffi- 
cient development,  the  desired  density  is  not  obtained,  pour  off  and  wash 
the  plate,  and  employ  a  fresh  developer. 

Of  late  years  the  "tank"  or  slow  developing  process,  has  been  used 
by  some  skiagraphers.  The  tank  development  is  to  be  recommended  for 
plates  which  have  not  received  full  exposures  and  for  the  smaller  size 
plates.  It  is  claimed  that  the  length  of  time  to  which  the  plate  is  sub- 
jected to  comparatively  weak  developing  solution  (40  to  60  minutes),  will 
bring  out  much  more  detail  than  the  application  at  once  of  a  more  vigor- 
ous developer.  However,  for  fully  timed  plates,  I  would  prefer  the 
methods  recommended  above.  The  following  is  Mr.  Cramer's  formula  : 

STOCK  SOLUTION. 

Water 32    oz.  (1000  c.  c.) 

Carbonate  of  soda  (dry) 2    oz.  (62  grams.) 

Sulphite  of  soda  (dry)  according  to  desired 

color  of  negative 1  to  1J  oz.         (32-48  grams. ) 

Bromide  of  ammonium 30  grains.  (2  grams. ) 

Citric  acid 30  grains.  (2  grams.) 

Hydrochinone 1  dram.  (4  grams.) 

<dycin 2  drams.  (8  grams.) 

Metol 2  drams.  (8  grams. ) 

Pyro 4  drams.  (16  grains. ) 

Dissolve  the  chemicals  in  given  rotation. 

To  preserve  the  stock  solution,  we  recommend  filling  small  bottles 
of  the  exact  size  to  hold  just  enough  for  making  the  diluted  solution 
for  tin-  tank.  The  bottles  should  be  quite  full  and  tightly  corked. 

FOR  USE : 

Water 120  ounces. 

Stock  solution 6  ounces. 

The  developer  should  IM-  used  fresh,  and  its  temperature  kept  Let  \\een 
60°  and  05°  F.,  until  development  is  completed. 


FIG.  106.— Envelo  developer.    (Lyon  Camera  Co.) 


FIG.  107.— Automatic  tray-rocker.    (Rontgen  Manufacturing  Co.) 


THE  PRINCIPLES  OF  TECHXir.  227 

It  is  necessary  to  observe  the  following  rules  in  handling  the  developer: 

Xo.  1.  Immerse  the  plates  in  a  tray  of  cool  water  before  putting  them 
in  a  tank. 

Xo.  2.  Immediately  after  immersing  the  plates  in  the  tank  solution, 
move  the  plates  up  and  down  with  a  quick  motion,  to  prevent  air-bells  or 
bubbles  forming  on  the  surface  of  the  film. 

Xo.  .°>.  After  the  plates  have  been  in  the  tank  from  five  to  ten 
minutes,  lift  each  plate  out  of  the  tank  and  reverse  its  position,  by  plac- 
ing that  end  of  the  plate  which  was  at  the  top  of  the  tank  to  the  bottom. 
This  will  prevent  the  appearance  of  streaks,  which  are  sometimes  found 
in  tank  development. 

Xo.  4.  It  is  well  to  rock  or  shake  the  tank,  at  least  once  in  every  five 
minutes,  during  development.  This  often  prevents  the  appearance  of 
streaks  or  spots  in  the  negatives. 

The  Envelo  developer  (Fig.  106)  is  an  extremely  simple  device, 
designed  to  develop  two  plates  at  one  time,  by  the  tank  or  stand  method. 
It  is  constructed  of  metal,  heavily  nickeled  on  the  outside,  and  coated  on 
the  inside  with  a  liquid  proof  composition. 

When  the  plates  are  large,  and  slow  development  is  aimed  at ;  in 
order  to  save  time,  resort  may  be  made  to  the  tray-rocker  (Fig.  107} 
which  works  automatically  through  the  agency  of  an  electric  motor. 

Fixing. — After  development,  the  plate  is  washed  in  the  tray  with 
running  water,  instead  of  the  usual  method  of  washing  it,  when  removed 
from  the  tray.  This  prevents  breakage  of  the  plate  and  likewise  contact 
with  the  developer,  which  would  cause  irritation  to  the  fingers. 

The  process  of  fixing  dissolves  out  all  the  silver  bromide  unacted 
upon  by  the  light  or  developer.  Allow  the  plates  to  remain  in  the  fixing 
bath  for  three  to  five  minutes,  after  the  chemical  agent  has  been  com- 
pletely removed  ;  this  will  insure  permanency,  freedom  from  stains,  and 
perfect  hardening.  After  all  ;' whiteness"  has  disappeared  from  the 
glass  side,  bring  ' '  the  negative ' '  to  the  light.  Leave  it  five  minutes  longer 
in  the  solution,  to  allow  for  thorough  fixing,  as  this  plate  has  a  thick 
double  coated  emulsion. 

The  acid  chrome  Jlcing  bath  I  largely  employ,  as  it  does  not  discolor 
and  keeps  longer  than  the  plain  hypo  fixing  solution.  It  is  made  as 
follows  : 

AVater 100  oz.  (3000  c.  c.) 

Sulphuric  acid 3  oz.  (90  c.  c.) 

Sulphite  of  soda 4  oz.         (120  grams.) 

AVlu'ii  dissolved,  add — 

Hyposulphite  of  soda 2  Ibe. 

Dissolve,  and  add — 

Chrome-alum,  from  one  to  two  ounce?,  previously  dissolved  in  20 
ounces  of  water.  Follow  by  adding  water  to  make  a  total  of  160  ounces. 


ELECTRO-THERAPEUTICS. 

In  hospitals  and  large  laboratories  it  is  useful  to  employ  two  large 
wooden  boxes  that  act  as  tanks.  (Fig.  108.)  In  the  Philadelphia 
Hospital  I  have  these  boxes  divided  into  different  sized  compartments 
to  accommodate  the  various  sized  plates.  Each  compartment  has  six 
vertical  grooves,  for  holding  six  plates.  One  of  these  tanks  contains 
the  acid  hypo  sufficient  for  six  mouths'  use.  The  other  tank  is  similarly 
Constructed,  in  which  the  water  enters  at  the  bottom  and  circulates 
to  the  top,  and  then  overflows  into  a  discharging  pipe. 


Fro.  108.— Author's  washing  tank.    The  fixing  tank  is  similar  in  construction. 

Washing.—  After  fixing,  washing  must  be  quickly  and  thoroughly 
done.  One  hour's  washing  with  running  water  is  sufficient ;  if  the  sup- 
ply be  not  so  accessible,  place  the  negative  in  a  flat  dish  and  constantly 
rock  for  five  or  ten  minutes.  Change  the  water  and  repeat  the  process 
for  one-half  to  three-quarters  of  an  hour.  Remove  the  negative,  a-ain 
wash  under  the  spigot,  using  a  pledget  of  cotton  to  wipe  off  any  foreign 
particle  adhering  to  the  gelatine  coating. 

Drying. — Dry  the  negative  in  a  room  of  moderate  temperature,  in 
which  a  ventilator  supplies  plenty  of  air.  Do  not  dry  in  the  sun,  as 


THE  PRINCIPLES  OF  TECHNIC.  :."_'«» 

sunlight  produces  softening  and  increases  the  density  of  the  film.  To 
dry  a  negative  hurriedly. — /.  <".,  in  five  or  ten  minutes, — lay  it  in  a  bath  of 
alcohol  after  washing  thoroughly,  or  put  before  au  electric  fau. 

The  negative  must  be  completely  dried  iu  one  room.  To  take  it  par- 
tially dried  into  another  room  and  there  complete  the  process,  will  result 
in  the  finished  negative  offering  a  difference  in  densities.  During  the 
summer  season  the  negative  becomes  denser  than  in  winter. 

Hardening. — After  fixing  the  negative,  wash  and  place  it  iu  the 
following  : 

Water 4  ounces       (120  c.  c.) 

Formaldehyde 1  ounce          (30  c.  c. ) 

Keep  in  this  solution  from  five  to  ten  minutes,  rocking  the  tray  from 
time  to  time.  If  the  solution  is  made  too  strong  the  film  may  peel  off. 
If  hardening  is  done  before  the  fixing,  then  the  fixing  process  should 
require  more  than  usual  time.  This  will  frequently  be  of  necessity  in  hot 
climates  and  during  the  hot  seasons  in  temperate  climates. 

C.  IMPKOVEMEXT  OF  THE  NEGATIVE. 

Intensification. — This  process  with  proper  exposure  and  development 
is  seldom  required,  except  for  special  purposes,  i.  e.,  for  under  exposed 
or  under- developed  plates.  The  negative  is  first  well  washed  and  then 
placed  in  the  following  : 

Mercuric  bichloride 200  gr.         (13.3  grams.) 

Potassium  bromide 120  gr.  (8.0  grams.) 

Water 6i  oz.  (200  c.  c.) 

Keep  the  plate  in  this  solution  a  short  time,  when  it  will  be  observed 
to  be  bleached  uniformly  white,  assuming  the  appearance  of  a  positive  ; 
the  longer  the  negative  is  bleached,  the  denser  it  will  become.  It  is 
again  thoroughly  rinsed  and  washed  under  the  spigot  for  at  least  a  half 
hour  in  running  water,  and  then  blackened  in  the  following  solution  : 

Sodium  sulphite 1  oz.  (30  grams.) 

Water 4  oz.  (120  c.  c.) 

or 

Ammonia 20  min.  (1  c.  c.) 

Water   1  oz.  (30  c.  c. ) 

It  now  being  blackened,  it  is  again  washed,  followed  by  drying. 
The  least  yellowish  east  indicates  that  the  negative  has  not  been  washed 
sufficiently  after  the  bleaching.  The  prints  of  such  negatives  show  the 
soft  tissues  very  faintly,  producing  a  great  contrast,  and  on  account 
of  their  great  density  they  print  very  slowly. 


•_'.;<)  ELECTKO-THKRAPKrTirs. 


General  n-ilnHnm  is  used  when  the  negative  is  very  dense,  as  a 
result  of  over  exposure,  over  development,  or  where  there  is  an  excessive 
aim  >  ii  MI  of  alkali  present  in  the  developer.  To  correct  this  nse  the 
following  solution  : 

A.—  Water  .....................................   16  oz.  (500  c.  c.) 

Hyposulphite  of  soda  .......................  1  oz.  (30  grains.) 

B.—  Water  ......................................  16  oz.  (500  c.  c.) 

Potass,  ferricyanide  .........................  1  oz.  (30  grains.  } 

Mix  8  parts  of  solution  "A"  and  one  part  of  solution  "B,"  ami  u.<e  in  sulxlued 
daylight. 

The  negative  can  be  placed  in  this  solution  directly  after  fixing. 
If  a  dry  negative  is  to  be  reduced,  it  must  be  soaked  in  water  for  at  least 
half  an  hour,  before  applying  the  solution.  To  avoid  streaks,  always 
rinse  the  negative  before  holding  it  up  for  examination.  As  soon  as 
sufficiently  reduced,  wash  thoroughly.  When  not  in  use  keep  solution 
"B"  protected  against  the  action  of  light. 

A  gradual  uniform  reduction  will  take  place,  its  rapidity,  of  course, 
depending  upon  the  quantity  of  potassium  ferricyanide  added.  When 
sufficiently  reduced,  wash  and  thoroughly  dry.  To  reduce  locally,  apply 
carefully  with  a  brush  or  cotton  some  of  the  solution  on  the  wet  nega- 
tive, allowing  it  to  remain  until  sufficiently  reduced;  follow  by  thor- 
oughly washing  and  drying. 

The  other  reducing  agent  consists  of  persulphate  of  ammonia  in 
water.  One  part  to  forty  is  strong  enough  for  most  purposes  (J  oz.  to 
10  ounces).  This  solution  does  not  keep  well,  and  should  be  made  as 
required.  Its  action  on  the  plate  must  be  carefully  watched  —  it  acts 
slowly  in  the  beginning,  and  then  all  of  a  sudden  very  rapidly.  After 
sufficient  reduction,  rinse  thoroughly,  and  place  in  a  10  per  cent,  solution 
of  sulphite  of  soda.  Wash  well  again  and  dry. 

There  is  a  great  difference  in  the  action  of  these  two  reducers. 
Potassium  ferricyanide,  like  most  reducers,  attacks  the  fine  details 
more  readily  than  the  denser  parts,  the  negative  becoming  harder  ami 
thinner.  The  persulphate  reducer,  on  the  contrary,  appears  to  reduce 
the  denser  pails  more  in  proportion,  so  that  the  negative  becomes 
slightly  Hatter. 

Local  l!«Jiirtion.  —  This  consists  of  bringing  in  contact  with  a  certain 
part  of  the  negative  some  reducing  agent,  destroying  contrast  to  some 
extent.  Let  us  suppose  a  negative  having  a  printing  effect  of  faintly 
bringing  out  the  fleshy  |>art  and  deeply  the  osseous  part  :  should  we 
dexire  to  bring  out  more  heavily  the  fleshy  part,  we  employ  what  is 
termed  the  local  reducer.  To  place  this  only  on  the  k'tleshy"  part  of 
the  negative  requires  a  great  deal  of  skill  —  the  effect  being  to  further 


THE  PRINCIPLES  OF  TECHNIC.  231 

reduce  the  silver  salt,  thus  giving  more  chance  for  the  rays  of  light  to 
penetrate  the  negative  and  printing  the  paper  more  heavily.  The  best 
results  in  local  reduction  can  only  be  obtained  by  constant  practice.  In 
local  reduction  the  plate  must  be  previously  wet,  as  otherwise  a  streaked 
appearance  will  result. 

Causes  and  Prevention  of  Faulty  Negatives.  Fogging. — A  total  black- 
ening of  the  plate  under  development  is  distinguished  from  other 
types  of  fogging  in  that  the  former  remains  clear  at  its  edge.  Fog 
also  results  from  a  developer  containing  too  much  alkali,  too  high  a 
temperature,  or  exposure  to  other  rays  than  those  emanating  from 
the  Crookes  tube.  Improper  or  too  much  light  in  the  dark  room  also 
causes  fogging.  General  fogging  cannot  be  remedied ;  the  negative, 
however,  may  be  sufficiently  cleared  by  a  reducer,  followed  by  intensi- 
fication. 

Stains. — Deep  yellow,  orange,  or  brown  stains  appearing  gradually 
either  in  patches  or  all  over  the  plate  may  result  from  imperfect  fixing 
or  incomplete  washing  after  fixing.  Another  cause  for  these  stains  is 
decomposed  hypo  in  the  film  by  improper  washing,  or  the  use  of  alum 
or  acids.  Over  developing  frequently  causes  greenish  stains  (excess  of 
reducing  agent). 

Spots. — Spots  or  pin-holes  in  negatives  are  usually  due  to  air- 
1  nibbles  and  decomposition  of  the  films.  Small  clear  spots  generally 
result  from  dust  particles.  Another  type  of  transparent  spot, 
irregular  in  shape,  results  from  the  scum  of  the  developer.  This  is  only 
seen  on  the  surface  of  very  old  developers.  Sediment,  accumulating  in 
the  trays,  graduates,  and  solution  bottles,  may  come  in  contact  with 
the  film,  thus  interfering  with  the  action  of  the  developer,  the  result 
being  spots.  Particles  of  uudissolved  developer  (pyrogallol)  adhering 
to  the  film  produce  irregular  dark  spots.  Cleanliness  in  all  the  steps 
of  the  developing  process  is  the  only  preventive  against  the  formation 
of  spots. 

D.  PRINTING  (POSITIVE),  TONING,  AND  MOUNTING. 

The  X-ray  image  of  the  negative  may  lie  printed  on  paper  as  in 
ordinary  photography.  All  diagnoses,  as  far  as  practicable,  should  be 
made  from  readings  from  the  negative  instead  of  from  the  print.  There 
are  instances,  however,  where  information  may  be  gained  from  the  print 
which  inadvertently  had  been  overlooked  in  the  interpretation  of  the 
negative.  Another  advantage  in  using  the  print  is  that  it  may  be  passed 
among  a  class  of  students  for  study,  a  procedure  that  might  endanger  a 
valuable  negative.  A  properly  exposed  and  well  developed  negative 
usually  serves  to  produce  a  good  print  on  almost  any  reliable  paper.  The 
commonest  printing-out  paper  used  in  this  work  is  the  ordinary 


232  ELECTRO-THERAPEUTICS. 

••albnma,"  the  printing  of  which  is  conducted  by  sun-light.  The 
advantage  of  this  paper  is  that  the  strength  of  printing  process  may  be 
easily  controlled. 

u  Dodging"'  is  a  method  employed  for  reducing  inequalities  of  a  print 
from  a  good  negative.  We  can  best  understand  this  method  by  citing  an 
example.  Let  us  take  a  negative  of  the  hand  ;  it  is  placed  in  a  regular 
printing  frame  as  already  referred  to.  We  are  all  aware  of  the  fact  that 
the  earpo-metacarpal  part  of  the  negative  has  been  reduced  by  the  devel- 
oper to  a  less  extent  than  the  phalaugeal  portion.  Therefore  in  the  print 
the  former  portion  would  be  shown  more  strongly  than  the  latter,  because 
more  rays  can  come  in  contact  with  the  paper.  In  order  to  equalize  the 
print,  we  " dodge"  the  carpo-metacarpal  portion  of  the  hand  by  con- 
stantly moving  a  piece  of  card-board  above  it, — L  e.,  we  shield  it  against 
further  action  of  the  light  rays.  This  permits  of  the  phalaugeal  portion 
being  printed  to  the  extent  desired.  Were  we  to  cover  the  carpo-meta- 
carpal portion  by  laying  card-board  over  it,  without  moving  it,  a  divid- 
ing line  would  be  readily  discernible,  being  exactly  the  opposite  of  what 
we  desire  to  achieve. 

Ground- Glass  Substitute. — The  glass  surface  of  the  plate  is  cleaned  of 
all  dust  particles,  finger  marks,  etc.,  and  a  solution  of  certain  gum  resins 
in  ether  called  ground-glass  substitute  is  poured  evenly  over  the  surface, 
precaution  being  exercised  to  prevent  the  liquid  from  coming  in  contact 
with  the  film.  The  ether  evaporates  more  rapidly,  leaving  behind  an 
even  coating  of  gum  resin,  which,  adhering  firmly,  gives  a  ground  glass 
appearance.  The  negative  may  now  be  " evened  up"  by  daubing  burnt 
umber  into  the  gum  layer  corresponding  to  those  parts  which  are  "  thin." 
To  even  up  a  negative  requires  skill,  and  in  order  to  guard  against  any 
errors  I  advise  the  use  of  a  print  from  the  negative  before  it  has  been 
prepared,  thus  acting  as  a  guide.  If  the  negative  is  uneven,  scrape  the 
ground-glass  substitute  from  those  parts  that  are  too  opaque  to  the  rays, 
thus  allowing  of  the  easy  passage  of  the  latter.  Soft  negatives  should  be 
printed  with  tissue  paper  over  the  printing  frame.  With  a  little  practice, 
the  inexperienced  will  rapidly  learn  the  art  of  developing.  It  is  better 
that  he  do  this  work  himself  than  to  rely  on  the  services  of  professional 
photographers. 

Developing  Paper*. — Velox  and  bromide  papers  can  only  be  printed 
in  dark  rooms  by  artificial  light,  the  sensitized  surface  of  the  paper  being 
placed  against  the  gelatine  side  of  the  negative,  and  the  printed  image  is 
l.rnught  out  by  a  process  of  developing.  The  advantage  of  these  papers  is 
tin-  rapidity  with  which  tin-  printing  is  done  without  the  aid  of  sunlight. 
Tin-  time  of  exposure  to  artificial  light  can  be  ascertained  only  by  follow- 
ing (fee  directions  and  by  experience.  Velox  and  bromide  paper  should  be 
v!:-\Ho|x'd  according  to  the  "instructions"  accompanying  each  package. 


THE  PRINCIPLES  OF  TECHXIC.  233 

Toning  Process. — Albuiua  paper,  after  being  printed,  should  be 
trimmed,  and  then  washed  in  running  water  until  it  ceases  to  be  "milky." 
The  prints  should  now  be  placed  face  to  back,  one  upon  the  other,  and 
introduced  into  the  toning  solution.  The  lowest  print  is  then  removed 
and  placed  upon  the  uppermost,  continuing  this  process  for  some  time. 

TONING  SOLUTION. 

Chloride  of  gold 20  gr.  (1.25  grams. ) 

Acetate  of  soda 1  oz.  (30  grams.) 

Water 20  oz.  (625  c.  c. ) 

Keep  slightly  alkaline  by  frequently  adding  sodium  bicarbonate. 
Of  the  stock  solution  take  an  ounce,  dilute  it  with  ten  ounces  of  clear 
water ;  it  is  then  ready  for  use. 

Put  the  prints  into  this  solution;  keep  them  moving,  thus  insuring 
even  toning.  If  the  toning  be  too  slow,  a  few  drops  of  the  stock  solution 
should  be  added  to  the  diluted  toning  solution.  On  the  other  hand,  if  the 
toning  is  too  rapid,  a  small  quantity  of  water  should  be  added.  Usually 
from  15  to  20  minutes  are  required  to  bring  out  an  even  and  proper 
tone.  After  the  toning  process  is  completed,  the  prints  are  thoroughly 
washed  for  some  time  in  running  water.  The  prints  are  next  introduced 
into  a  fixing  bath  which  consists  of 

Hyposulphite  of  soda 2  oz.         (60  grams.) 

Water 20  oz.          (600  c.  c.) 

In  this  solution  they  should  be  allowed  to  remain  for  at  least  15  or 
20  minutes,  keeping  them  in  motion.  All  these  processes  should  be 
conducted  in  a  dimly  lighted  room. 

Mounting. — After  the  prints  have  been  thoroughly  fixed,  they  are 
again  wrashed  for  several  hours  in  running  water.  They  are  next  placed 
separately  on  a  plate  of  glass  (face  downward)  before  drying,  and  all  the 
wrinkles  are  rolled  out  by  blotting  paper.  The  back  of  each  print  is  now 
painted  with  photographic  paste  and  mounted  on  stiff  card-board.  Blot- 
ting paper  is  placed  on  the  face  of  each  print,  and  a  roller  used  before  the 
print  has  dried,  to  remove  any  wrinkles. 

/'o.s/7/Yr.s. — Another  method  of  printing  consists  in  placing  the  X-ray 
negative  into  a  regular  printing  frame,  and  a  sensitive  plate  behind  it. 
Kverythiug  being  in  total  darkness,  light  a  match  and  expose  the  plate 
for  5  or  8  counts.  Develop  the  plate  in  the  usual  manner,  the  result  be- 
ing a  ^pnxiflrc."  These  positives  are  the  exact  size  of  the  negative 
(contact  print),  while  transparencies  and  lantern  slides  are  reduced  in 
si/.e.  It'  prints  are  made  from  these  positives,  the  bones  will  appear 
white,  i  he  fleshy  ] tarts  dark,  etc.,  similar  to  the  appearance  of  the  original 
negative. 


234  ELECTRO-THERAPEITK  s. 


<ni>l  Lantern  Slides  or  />/V//;o,sv7//r.s.  —  The  reduced  trans 
parencies  appear  with  fuller  detail  and  are  easily  handled  and  convenient 
for  exhibiting  purposes.  The  reduced  transparency  can  be  obtained  by 
putting  the  original  negative  in  a  camera  or  window,  the  negative  being 
transilluininated  and  focused  over  a  4  x5  inch  (10x12.5  cm.)  sensitive 
contrast  plate  and  developed.  If  a  smaller  sized  plate  be  used,  3^  x  4 
inches  (8.2  x  10  cm.),  we  obtain  a  lantern  slide  for  projection.  In 
making  prints  from  these  negatives,  the  bones,  for  example,  will  appear 
white,  a  circumstance  that  will  often  prove  useful. 

Batelli  and  Garbasso  were  the  first  to  suggest  the  wisdom  of  obtain- 
ing reduced  photographs,  from  images  observed  on  the  fluoroscopic 
screen,  the  advantage  being  that  small-sized  plates  may  be  readily  em- 
ployed. But  certain  disadvantages  of  the  method  at  once  present  them- 
selves. The  image  on  the  screen  must  be  steady,  and  there  is  required 
an  ortho-chromatic  plate,  with  a  long  exposure,  as  the  image  formed  is 
yellow  in  color.  The  process  is  not  well  developed  as  yet,  but  when  it 
is,  an  additional  precaution  will  be  the  protection  of  the  camera  from 
the  rays. 

IV.  Interpretation  of  X-ray  Negatives. 

This  is  more  difficult  than  making  the  negative,  because  of  the 
superimposition  of  shadows  of  varying  densities.  The  trained  eye  of 
the  X-ray  specialist  alone,  can  indisputably  interpret  the  negative  with 
any  degree  of  correctness. 

The  negative  should  be  a  satisfactory  one  of  the  special  structures 
under  examination.  If  it  is  found  to  be  unsatisfactory,  a  duplicate  should 
be  made  ;  if  this  is  not  easily  procurable,  the  negative  can  be  improved 
by  the  process  that  I  have  mentioned  in  the  chapter  devoted  to  pho- 
tography. In  those  cases  where  difficulty  is  encountered  in  arriving  at 
a  positive  diagnosis  it  is  imperative  that  a  duplicate  be  made  in  order 
to  confirm  the  earlier  diagnosis. 

A  blurred  negative  cannot  be  remedied  and  is  in  every  way  inferior 
to  an  under-  or  an  over-exposed  plate. 

The  skiagrapher  should  keep  full  data  of  the  technie  when  making 
tin-  negative.  He  should  always  endeavor  to  interpret  it  correctly  and 
to  compare  it  with  a  negative  of  the  corresponding  part  in  the  same 
individual;  he  should  study  each  part  and  its  anatomy,  and  make  him- 
self thoroughly  informed  upon  every  subject  that  comes  to  him  for 
diagnosis  and  opinion. 

///;;/'  to  View  thr  \ff/(itive.  —  It  is  of  prime  importance  to  know  the 
exact  relations  of  tiie  lube  and  the  position  of  the  part  to  the  plate. 

'I'll.-  X-rays  emanate  from  a  small  point  on  the  anode,  diverge,  and 
then  traverse  the  object,  casting  enlarged  shadows  on  the  fluoroscope  or 


THE  PRINCIPLES  OF  TBCHNIC.  235 

plate.  The  collect  ions  of  silhouettes  are  therefore  superimposed — /.  c., 
there  is  a  composite  of  the  shadows  of  the  object  near  the  tube  ami  those 
near  the  plate,  "When  a  negative  is  dry  and  ready  to  be  examined,  the 
eye  of  the  skiagrapher  or  observer  should  take  the  place  of  the  anode  of 
the  Crookes  tube,  the  film  or  gelatine  side  facing  the  interpreter's  eye, 
equal  to  the  distance  of  the  tul>e  from  the  plate. 

Suppose  that  the  right  palm  is  in  contact  with  the  sensitive  side  of 
the  plate,  when  examining  the  negative,  it  follows  that  the  negative  will 
be  seen  when  the  gelatine  side  is  toward  the  observer's  eye  ;  but  if  the 
observer's  eye  corresponds  to  the  Crookes  tube,  then  the  dorsum  of  the 
hand  will  be  brought  into  view.  On  the  contrary,  with  the  glass  side 
toward  his  eye,  the  observer  views  the  dorsum  of  the  left  hand  or  palmar 
view  of  the  right  hand,  which  is  equal  to  the  fluoroscopic  view  or  a 
print.  For  instance,  a  patient  is  in  the  dorsal  position,  the  plate  placed 
against  the  back  and  the  tube  over  the  sternum,  with  the  gelatine  side 
(film)  toward  the  observer's  eye  and  the  eye  corresponding  to  the 
Crookes  tube  ;  then  this  negative  will  show  as  though  the  observer  were 
looking  through  the  anterior  wall  of  the  thorax  ;  the  left  side  of  the 
patient  will  be  his  right  side  and  vice  versa. 

If  you  examine  this  negative  with  the  glass  side  towards  your  eye 
(which  is  equal  to  placing  the  fluoroscope  to  the  back,  or  looking  at  a 
print)  the  right  side  of  the  patient  will  be  your  right  side,  etc. 

If  a  ventral  or  anterior  view  is  taken,  place  the  plate  in  front  of  the 
chest  and  the  tube  posterior  ;  when  this  negative  is  examined  (film  side 
towards  the  eye),  the  patient  is  viewed  through  the  back,  his  right  side 
will  be  your  right  side,  etc. ,  but  if  you  look  at  the  glass  side  of  the  neg- 
ative, then  this  will  be  equal  to  the  fluoroscopic  view  or  a  print,  i.  e.,  the 
patient's  right  side  will  be  your  left  side,  etc. 

I  prefer  to  make  the  examination  or  interpretation  directly  from  the 
negative  and  not  from  the  prints,  because  prints  reverse  the  views.  If 
we  look  at  prints  of  the  anterior  view  of  the  thorax,  our  eyes  do  not 
correspond  to  the  anode  of  the  Crookes  tube,  but  we  are  looking  at  the 
front  of  the  chest  and  rays  are  coming  through  the  back  of  the  patient ; 
we  call  this  the  ventral  view,  etc., — /.  e.,  the  view  or  part  that  is  next  to 
the  gelatine  side  of  the  plate,  the  fluoroscope,  or  print,  or  its  equivalent 
to  the  negative  glass  side  toward  our  eyes.  The  negatives  should  be 
placed  or  held  with  the  gelatine  side  toward  the  examiner's  eyes,  because 
in  this  position,  we  look  through  the  object  and  see  its  shadows  more 
correctly  and  truer  in  their  relation  to  each  other.  There  will  likewise 
be  no  reflection  of  light  from  the  film,  as  there  will  be  from  the  glass 
side.  The  negative  can  be  held  by  the  examiner  who  manipulates  it,  by 
viewing  it  from  different  angles,  or  an  assistant  holds  the  plate  and  the 
operator  examines  it  from  different  distances  and  angles. 


236 


ELECTRO-THERAPEUTICS. 


A  better  plan  is  to  place  the  negative  in  a  window,  lower  the  cur- 
tain, and  allow  the  light  to  come  through  the  negative.  I  often  prefer 
to  place  the  negative  iu  the  window  of  the  dark  room  and  examine  it 
cither  alone  or  by  a  similar  negative  of  the  corresponding  part  of  the 
same  person;  if  this  be  not  possible,  I  employ  the  negative  of  sonic 
other  person  and  then  compare  them  side  by  side.  Another  easy  method 
is  to  place  the  negative  in  a  photographer's  retouching  desk,  which  is  so 
very  convenient  for  small  negatives. 

I  have  devised  a  viewing  box  (Fig.  109)  which  I  employ  at  the 
Philadelphia  Hospital.  This  box  accommodates  any  sized  negative  and  is 
capable  of  rotation,  and  thus  without  any  displacement  the  negative  can 
be  viewed  at  any  angle  and  also  in  the  vertical  or  horizontal  position. 


FIG.  109.— Author's  ncriitive-viewinff  box. 


This  box  contains  three  series  of  eight  c.  p.  lights  behind  the  ground 
glass.  When  a  dim  or  weak  light  is  desired  for  less  dense  negatives,  one 
series  of  lamps  is  lighted  ;  if  strong  light  is  desired,  the  ~No.  2  switch  is 
turned  on  and  greater  illumination  is  produced.  This  box  contains  per- 
forations and  is  lined  with  asbestos.  The  preferable  light  for  the  exam- 
ination of  negatives  is  white  (day)  light  or  the  electric  light.  The 
intensity  of  the  light  can  be  regulated  by  the  interposition  of  either 
ground  glass  or  a  rheostat,  as  necessity  requires. 

A.  FOKKI<;\  UODIKS. 

In  interpreting  a   negative  for  a  foreign  Ixxly,  exclude  all  possible 
errors,  such  as  white  spots  produced  by  air  bubbles  during  development, 


Till-]  PRINCIPLES  OF  TECHXIC.  237 

the  presence  of  iodoform,  lead  water  and  laudannni.  etc..  that  may  In-  on 
the  bandage  or  dressing.  Metallic  foreign  bodies  will  eclipse  all  other 
shadows.  When  semi-opaque  bodies  east  their  shadows  on  those  of  the 
bones  the  contrast  may  be  only  very  slight,  especially  so.  when  the  plates 
are  undeveloped.  Small  bodies  in  the  deeper  portions  of  the  body  (as 
for  instance  in  the  abdomen  and  in  bony  cavities,  as  the  eye)  may  defy 
detection  if  the  time  of  exposure  is  prolonged  and  secondary  rays  produce 
fogging  on  the  plate.  This  occurs  especially  when  the  foreign  body  is 
non-metallic, — i.  e.,  a  fragment  of  stone,  etc. 

B.  FRACTURES  AND  DISLOCATIONS. 

Green -stick  fractures  and  impacted  fractures  are  often  difficult  to 
recognize.  If  the  rays  do  not  penetrate  the  separated  fragments,  the 
shadows  will  be  superimposed,  and  the  characteristic  dark  Hue  on  the 
negative  will  not  be  visible  ;  in  impacted  fractures  instead  of  this  dark 
line  there  will  appear  an  increased  white  shadow.  Epiphyseal  lines 
should  not  be  lost  sight  of.  The  elbow-joint  in  children  should  lie 
compared  with  the  corresponding  normal  side. 

Fractures  of  th<>  Hip-Joint.  — In  these  fractures  note  the  changes  oc- 
curring, even  if  the  dark  line  ou  the  negative  is  not  visible  ;  and  also  look 
for  any  change  in  the  continuity  of  the  periosteum,  the  shape  and  relation 
of  the  femoral  neck  to  the  trochauter,  etc.  Compare  the  normal  hip-joint 
with  the  affected  one,  and  take  a  skiagraph  of  both  hips  on  one  large 
plate,  being  careful  to  observe  the  position  of  the  feet. 

Dislocations. — This  condition  can  be  discerned  easily.  The  relations 
of  the  heads  of  the  bones  may  often  be  disturbed  or  changed  either  by  a 
peculiar  position  that  the  part  may  assume,  or  by  a  faulty  relationship 
in  the  position  of  the  tube  to  the  plate  ;  this  frequently  occurs  in  the 
shoulder-joint,  in  the  acromio-clavicular  articulation,  etc.  Intra- articular 
cartilages  are  transparent  to  the  rays  and  may  thus  be  mistaken  for  a 
dislocation. 

The  ventral  and  dorsal  positions  of  the  shoulder-joint  present  differ- 
ent appearances  on  the  negative. 

C.  DISEASES  AND  TUMORS  OF  THE  BONES. 

It  is  important  to  determine  if  the  growth  is  osseous  or  of  muscular 
origin.  Whenever  possible  the  shadow  should  be  cast  in  the  light  field, 
and  note  should  be  made  whether  the  shadow  is  attached  to  the  perios- 
teum or  to  the  central  portion  of  the  bone.  Do  not  diagnose  the  bony 
normal  ridges,  grooves,  or  projections  as  irregularities  of  the  compact 
portion  of  the  bone.  The  early  stages  of  any  special  bone  disease  are  dif- 
ferent iated  with  difficulty  from  other  osseous  diseases  by  the  appearance 


238  KLKITIH  >-TII  KK'AI'KUTICS. 

offered  on  the  negative,  as  nearly  all  bone  affections  produce  an  increase 
in  shadow  density.  Such  a  negative  may  assist  the  physician  as  to  the 
origin  and  the  exact  location  of  the  disease,  and  as  the  disease  advances 
the  characteriMic  appearance  of  that  particular  disease  of  the  bone  on  the 
negative  will  be  noticed. 

Callus. — The  appearance  of  callus  can  be  diagnosed  from  periostitis, 
or  other  diseases,  by  the  deformity  produced  and  because  the  shadows 
are  fusiform  and  encircle  the  ends  of  the  fragments. 

Diseases  of  Joints. — Endeavor  to  obtain  an  mtra-articular  space  as 
wide  as  possible.  Bandages  and  dressings  should  always  be  removed. 
Ordinary  arthritis  is  differentiated  with  difficulty  from  the  other  arth- 
ritic affect  ions  in  their  early  stages.  Pus  and  fluid,  whether  serous  or 
purulent,  cannot  be  easily  differentiated,  although  serum  casts  a  denser 
shadow  than  pus. 

Intra-articular  inflammation  with  exudation,  can  be  differentiated 
from  a  periarticular  inflammation,  because  the  intra-articular  space  of  the 
former  is  increased  on  account  of  the  tension  exerted. 

False  and  true  aukylosis  should  be  carefully  differentiated.  Bony 
ankylosis  may  be  excluded  by  the  absence  of  dense  shadows,  or  by  the 
obliterated  intra-articular  space,  which  is  absent  in  false  ankylosis.  In 
advanced  cases  deposits  of  tophi  are  demonstrable,  and  one  can  observe 
with  certainty  whether  the  disease  is  mtra-articular  or  periarticular  in 
origin. 

In  hip-joint  disease  or  in  any  other  disease  of  the  bone  or  joint,  the 
true  conditions  or  si£e  of  the  bone  may  be  altered,  diminished,  or  increased, 
either  by  being  nearer  to  the  plate  (as  the  result  of  atrophy  of  the  muscle 
from  disease),  by  disuse,  or  by  other  causes  that  may  exaggerate  the 
normal  size  of  the  bone  on  the  negative. 

D.  DISEASES  OF  THE  SOFT  STRUCTURES. 

It  is  very  difficult  in  these  conditions  to  skiagraph  or  to  obtain  a 
clear  shadow  on  the  negative,  and  even  when  once  obtained  it  cannot  be 
differentiated  from  similar  conditions,  as  lipoma,  sarcoma,  cyst,  etc.  A 
soft  negative,  full  of  details,  is  most  desirable,  and  may  be  easily  obtained 
by  slightly  under-developed  and  properly  exposed  plates. 

Brain  tumors  are  very  difficult  to  diagnose.  Thickness  of  hair, 
especially  in  female  subjects,  should  not  be  mistaken  for  a  neoplasm. 

E.  DISEASES  OF  THE  THORACIC  ORGANS. 

Negatives  of  the  thorax  should  be  examined  in  a  viewing  box.  The 
skiagniphcr  should  be  familiar  with  the  fluoroscopic  appearance  of  the 
normal  and  of  the  pathological  lung.  The  physical  examination  should 
always  pre<-..<lr  th,-  skiagraphic  examination.  When  the  plate  is  placed 


THE  PRINCIPLES  OF  TECHNIC.  239 

over  the  anterior  wall  of  the  thorax,  the  negative  will  reveal  the  cage-like 
appearance  of  the  thorax  ;  the  anterior  portions  of  the  ribs  will  appear 
sharp  and  distinct,  and  will  form  ail  angle  with  the  posterior  portion. 

If  the  negative  has  been  exposed  in  contact  with  the  back  of  the  pa- 
tient, then  the  posterior  portion  of  the  ribs  will  be  more  distinct  than  the 
anterior  portion,  the  latter  being  further  from  the  plate.  If  the  time 
of  exposure  is  prolonged,  these  anterior  portions  of  the  ribs  will  be 
indistinct  and  widely  separated.  The  shadow  of  the  diaphragm  will  be 
more  distinct  on  the  aifected  side,  being  less  mobile  during  the  exposure. 

In  comparing  the  transparencies  of  the  apices  of  both  lungs  in  right- 
handed  persons,  the  right  side  may  appear  lighter  on  the  negative. 

In  viewing  the  anterior  wall  of  the  chest  examine  the  intercostal 
spaces;  do  not  mistake  the  shadows  of  the  anterior  portion  of  the  first 
rib  (often  cast  between  the  2d  and  3d  intercostal  spaces),  or  the  sternal 
end  of  the  clavicle  (which  may  show  an  increased  shadow),  for  consoli- 
dation. The  shadows  of  the  sternum  require  most  careful  observation  and 
the  shadows  of  the  scapula  will  often  be  cast  outside  of  the  thorax.  The 
female  mammary  glands  throw  pronounced  shadows. 

In  the  incipient  stage  of  tuberculosis,  the  apices  of  the  lungs  must 
be  studied  with  great  care,  as  a  slight  degree  of  congestion  or  infiltration 
will  throw  a  shadow  on  the  affected  side.  If  one  apex  is  diseased,  the 
diagnosis  will  be  arrived  at  with  less  difficulty,  because  an  opportunity  is 
afforded  for  comparison  with  the  normal  apex.  Do  not  compare  the 
transparency  of  one  apex  with  other  portions  of  the  lung,  but  apex  with 
apex,  etc. ;  for  as  the  thickness  of  the  thoracic  wall  differs  in  different 
parts,  so  does  the  transparency  vary  in  the  same  person. 

Bronchial  or  lymphatic  glands  when  calcified  (and  which  are  tuber- 
culous), can  often  be  observed  without  difficulty  ;  small  areas  of  consoli- 
dations will  appear  as  irregular  scattered  light  patches.  Longitudinal 
streaks  on  each  side  of  the  heart  are  supposed  to  be  due  to  the  foldings 
of  the  pleurae,  when  the  latter  are  viewed  edge- wise.  Upon  the  nega- 
tive the  posterior  view  shows  the  ribs  very  clearly  and  distinctly,  and 
likewise  the  vertebra.  The  anterior  portions  of  the  ribs,  however, 
are  blurred,  because  the  posterior  ribs  are  nearer  to  the  plate  and  are 
immobilized. 

Abscesses  and  empyema  do  not  cast  shadows  so  dense  as  does  consoli- 
dation ;  neither  do  the  former  obscure  the  shadows  of  the  ribs.  Pleural 
thickening  is  differentiated  from  effusion  in  that  the  latter  casts  a  uniform 
and  more  dense  shadow ;  the  level  of  the  shadow  will  change  with  the 
position  of  the  patient  and  is  best  viewed  in  the  erect  or  sitting  posture. 
In  thickening  of  the  pleura  an  irregular  outline  is  discernible. 

In  contioti<l<ttion  the  shadows  are  larger,  more  irregular,  and  denser 
than  those  cast  by  the  ribs,  and  especially  noticeable  in  advanced  cases 


240  ELECTRO-THERAPEUTIC 'S. 

of  tuberculosis.  The  apex  alone  may  be  affected,  but  in  other  instances 
the  entire  lung  is  attacked.  It  is  thus  that  consolidation  is  differentiated 
from  effusion. 

Gavitations  are  characterized  by  dark  areas  surrounded  by  a  light 
field;  this  is  due  to  a  lessened  amount  of  tissue  for  penetration  by  the 
rays.  If  the  cavity  is  partly  filled  with  fluid  while  the  patient  is  in  the 
recumbent  posture,  the  fluid  gravitates,  and  the  dark  area  is  obliterated; 
but  in  the  erector  sitting  posture  the  level  of  the  fluid  will  be  visible 
when  it  is  of  considerable  size. 

Prior  to  a  paroxysm  of  severe  coughing,  if  a  fluoroscopic  or  skia- 
graphic  examination  be  made  with  the  patient  in  a  recumbent  position, 
and  another  examination  taken  subsequent  to  the  paroxysm,  the  cavity 
will  be  noticeable,  because  the  fluid,  pus,  etc.,  will  be  evacuated. 

Emphysema  is  manifested  by  excessive  darkness  on  the  negative,  due 
to  the  presence  of  air  in  the  lung,  as  is  also  observed  in  cases  of  pneumo- 
thorax,  etc. 

The  shadows  of  the  ventricles,  the  auricles,  and  the  aorta,  are  easily 
recognized  ;  for  a  detailed  account,  the  reader  is  referred  to  the  chapter 
devoted  to  the  Circulatory  System. 

I  have  made  stereoscopic  skiagraphs  of  the  thorax  which  are  very 
useful  in  differential  studies  in  pulmonary  and  cardiac  affections. 

F.  ALIMENTARY  SYSTEM. 

Stricture  of  the  oasophagus,  whether  due  to  a  growth  within  or  exter- 
nal to  and  compressing  the  oesophagus,  is  difficult  and  often  impossible  to 
differentiate  by  the  skiagraphic  appearance;  but  if  the  growth  is  within 
the  oesophagus  and  the  latter  cannot  be  dilated,  it  becomes  necessary  to  in- 
troduce an  oesophageal  bougie ;  on  the  other  hand,  if  the  growth  is  external, 
the  sound  can  be  introduced  by  displacing  the  growth  to  one  side. 

The  Stomach. — The  reader  is  referred  to  Chapter  V.,  Alimentary 
System. 

G.  GENITOURINARY  SYSTEM. 

Only  in  emaciated  individuals  are  the  shadows  of  the  kidneys  easy 
of  demonstration.  In  the  normal  individual,  shadows  of  the  kidneys  as 
seen  on  the  negative  are  very  unsatisfactory. 

Renal  calculi  should  not  be  mistaken  for  biliary  calculi,  intestinal 
concretions,  enteroliths,  tuberculous  foci,  or  abscesses.  Scars  and  accu- 
mulations of  sand  in  the  pelvis  of  a  kidney  may  in  some  cases  cause  an 
erroneous  diagnosis  to  be  made.  I  once  mistook  an  undissolved  capsule 
of  bismuth  for  a  calculus,  but  a  second  negative  showed  the  change  in  the 
position  that  the  capsule  assumed,  and  the  operation  was  postponed. 


THE  PRINCIPLES  OF  TECHXIC.  L>41 

Dr.  Heiiry  Hultz1  reported  a  case  in  which  fracture  of  the  transverse 
process  of  a  vertebra  would  have  been  mistaken  for  a  calculus  had  he  not 
made  a  stereo -skiagraph  of  the  condition.  Whether  a  calculus  is  in  the 
lower  part  of  the  ureter  or  in  the  bladder,  is  often  a  difficult  matter  to 
decide. 

There  are  three  methods  for  ascertaining  the  exact  location  of  a 
calculus.  1.  By  inflating  the  bladder,  when  the  shadow  cast  will  be 
darker  on  the  negative.  2.  By  injecting  water,  when  the  shadow  will 
be  seen  to  be  lighter  than  the  surrounding  structure.  3.  By  introduc- 
ing a  catheter,  when  the  presence  of  a  (small)  stone  in  the  ureter  will  be 
noticed  by  its  position,  and  relation  to  the  end  of  the  catheter.  By  the 
first  and  second  methods  the  relation  of  the  calculus  to  the  bladder  will  be 
observed. 

Several  small  round  white  spots  often  mistaken  for  calculi  may  be 
noticed  along  the  left  line  of  the  ureter.  They  are  frequently  situated  in 
a  curved  line  and  are  more  frequent  on  the  left  side  than  on  the  right,  or 
sometimes  on  both  sides  of  the  same  patient.  They  commonly  occur  after 
the  thirtieth  year.  Their  true  nature  is  a  disputed  matter.  Some  believe 
them  due  to  the  presence  of  sesamoid  bones  in  one  of  the  obturator 
tendons.2  Russell  H.  Boggs  is  of  the  same  opinion  ;  others  incline  to  the 
belief  that  they  are  calcified  glands. 

Dr.  Joseph  F.  Smith,1  of  Chicago,  believes  that  in  25  per  cent,  of  his 
cases  negatives  of  the  pelvis  contained  from  one  to  six  small  round 
shadows,  sometimes  on  one  side,  sometimes  on  both  sides,  in  the  vicin- 
ity of  the  ischiuui.  He  found,  by  dissections  of  cadavers,  that  these 
shadows  are  caused  by  small  bony  deposits  that  occur  in  the  pelvic  liga- 
ments, especially  in  those  attached  to  the  spiuous  process  of  the  ischiuni. 
I  concur  with  those  who  believe  that  these  spots  are  phleboliths.  Among 
the  latter  may  be  mentioned  Chas.  L.  Leonard,  Henry  K.  Pancoast,  and 
Max  Reichman.4  These  shadows  can  be  differentiated  from  those  of 
ureteral  calculi  by  passing  a  metallic  bougie  and  by  skiagraphiug  in  situ. 
If  these  shadows  are  outside  the  shadow  of  the  catheter,  they  are  evidently 
not  ureteral.  The  autopsy  of  one  of  my  cases  showed  the  presence  of  a 
phlebolith. 

TV.s/coZ  Calculi. — The  shadows  of  the  sacrum  and  coccyx  may  be 
superimposed  by  the  shadow  of  a  small  calculus,  hence  the  shadow  of  the 
latter  may  fail  of  differentiation.  This  is  also  true  of  the  shadow  of 
impacted  fecal  matter  in  the  rectum.  The  bladder  should  be  evacuated 
just  prior  to  the  X-ray  examination,  as  water  offers  a  barrier  to  the 

1  Transactions  of  the  American  Rontgen  Ray  Society,  1906,  page  158. 
1 E.  W.  Caldwell,  Medical  News,  April  22,  1905. 
3  Transactions  of  the  American  Rontgen  Ray  Society,  1906,  p.  157. 
4Fortschritte  a.  d.  Gebiete  der  Rontgenstrahlen,  Feb.  22,  1906. 
16 


LMi>  ELECTRO-THERAPEUTICS. 

I»;i-»age  of  rays.  I  have  frequent ly  seen  the  outline  shadows  of  the 
bladder,  which  are  so  valuable  in  determining  whether  the  calculus  is 
uretenil  or  vesical,  or  if  the  appearance  is  due  to  an  interfering  shadow. 

In  stricture  of  the  urethra,  by  the  introduction  of  a  bismuth  solution 
we  are  enabled  to  ascertain  the  location  of  the  stricture,  its  calibre,  etc. 

A  report  of  the  X-ray  negative  should  be  written  or  oral  and  should 
be  most  carefully  executed.  The  report  should  be  made  as  intelligible 
as  possible,  by  making  some  tracing,  marking,  etc. 

There  are  numerous  shadows  on  the  negative  that  defy  all  efforts  at 
interpretation  and  are  as  little  understood  to-day  as  they  were  when 
skiagraphy  was  first  presented  to  the  notice  of  the  medical  profession. 

V.  Stereo-Fluoroscopy  and  Skiagraphy. 
A.  HISTORY  AND  PRINCIPLES. 

The  application  of  the  principles  of  stereoscopy  to  skiagraphy  was 
first  employed  in  this  country  by  Professor  Elihu  Thomson  l  and  subse- 
quently used  abroad. 

Ch.  Bouchard2  claims  priority  of  the  discovery  for  Imbert  and  Bertin, 
of  Montpellier,  France,  but  this  is  erroneous,  as  the  latter  first  made 
known  their  studies  in  Comptes-Rendus,  March  30,  1896. 

Dr.  Mackenzie  Davidson  was  perhaps  the  first  investigator  to  pro- 
duce and  interpret  X-ray  photographs  by  this  method,  publishing  an 
article  in  the  Britixli  Medical  Journal  in  1898. 

Professor  G.  P.  Girdwood,  of  McGill  University.  Montreal,  Canada. 
made  extensive  use  of  this  method  in  studying  foreign  objects.  The 
leading  scientific  journals  of  Germany  have  published  many  articles  on 
this  subject,  describing  the  methods,  the  apparatus,  and  detailing  advan- 
tages gained  by  its  employment. 

In  October,  1901,  Dr.  Louis  Weigel,  of  Rochester,  exhibited  a  stereo- 
scopic outfit  before  the  members  of  the  New  York  Medical  Society,  and 
Dr.  A.  B.  Johnson,  of  New  York  City,  published  an  article  on  this  snl> 
ject  in  the  Xew  York  Medical  Record,  September,  1900. 

In  order  to  produce  a  stereoscopic  picture,  it  is  necessary  to  arrange 
a  pair  of  tubes  so  that  when  worked  simultaneously  they  will  present  on 
the  fluorescent  screen  a  double  set  of  outlines  fused  into  one.  To  bring 
out  this  effect  we  must  alternate  the  use  of  the  tubes,  and  so  choose  ihe 
intervals  that  the  continuity  of  vision  may  accomplish  the  fusion  of  the 
two  images.  (Figs.  110,  111.) 

The  anodes  ;nv  placed  about  6  cm.  distant  from  each  other.  They 
are  alternately  excited  by  a  single  coil,  but  preferably  by  individual 

Electrical  Engineering,  March  11,  18%. 
*  Trait£  Radiologie  M^dicale,  p.  661. 


THE  PRINCIPLES  OF  TErHXIO. 


243 


coils.  The  terminals  of  the  secondary  c'oil  are  connected  to  the  tubes 
alternately,  by  means  of  a  commutator  or  switch  worked  automatically. 
It  is  also  necessary  to  have  a  revolving  opaque  disk  containing  two 
apertures  on  directly  opposite  sides,  and  set  apart  from  each  other  at  a 
distance  corresponding  to  the  space  between  the  examiner's  eyes. 

If  the  sector  disk  and  the  automatic  switch  rotate  synchronously, 
and  are  so  adjusted  that  the  tube  on  the  left  side  becomes  luminous 
simultaneously  with  the  passing  of  the  aperture  for  the  eye  of  that  side, 


FIG.  110.— Principles  of  Brewster's  refracting 
stereoscope. 


FIG.  111.— Principles  of  Wheatstone's  reflecting 
stereoscope. 


there  may  l>e  observed  a  sharp  image  on  the  fluorescent  screen  between 
the  left  tube  and  the  perforated  disk  ;  this  is  suddenly  followed  by  an 
obscuration  of  the  vision  of  the  left  eye.  In  this  instance  the  tube  is 
suddenly  thrown  into  illumination  and  the  image  of  the  part  is  thrown 
upon  the  screen.  Dr.  Davidson l  constructed  such  an  apparatus. 

B.  STEREO-FLUOROSCOPY. 

Briefly,  this  stereoscopic  fluoroscope  consists  of  a  fluorescent  screen 
illuminated  by  two  tubes  which  spark  alternately.  A  rotating  disk  with 
appropriately  placed  slots  eclipses  each  eye  alternately  and  works  syn- 
chronously with  the  sparking  of  the  tubes.  Each  eye  sees  the  shadow 

1  Dr.  Mackenzie  Davidson  described  the  mechanism  of  his  invention,  together 
with  the  application  of  its  principles,  before  the  Rontgen  Ray  Society  of  London,  on 
December  6,  1900. 


244  ELECTRO-THERAPEUTICS. 

cast  from  erne  tube.  A  stereoscopic  image  i.s  thus  seen,  the  movements 
of  the  shutter,  etc.,  being  sufficiently  rapid  to  give  a  continuous 
illumination  of  the  screen. 

E.  W.  Caldwell1  uses  a  large  Crookes  tube  of  the  double  focus 
variety  (two  anodes)  at  a  distance  of  three  inches.  The  fluoroscope  is 
provided  with  a  shutter  which  permits  only  oiie  eye  at  a  time  to  view  the 
fluorescent  screen.  In  other  respects  the  apparatus  is  very  similar  to 
Davidson's  device. 

C.  TECHNIC  OF  STEREO-SKIAGRAPHY. 

In  brief,  the  technic  consists  of  obtaining  two  separate  skiagraphs 
of  the  same  part,  or  of  employing  two  different  sensitive  plates  without 
changing  the  position  of  the  parts,  but  in  alternating  the  position  of  the 
Crookes  tube  two  and  a  half  to  two  and  three  quarters  inches  (6  cm.), 
corresponding  to  the  distance  between  the  pupils.  (Fig.  112.)  Subse- 
quently these  two  negatives  or  skiagrams  should  be  examined  with  a 
special  instrument.  It  is  important  to  observe  that  the  part  on  which 
the  stereoscope  is  to  be  used  should  first  be  fluoroscoped  or  skiagraphed 
in  order  to  locate  accurately  the  seat  of  the  injury. 

For  use  in  stereoscopic  work,  a  plate-changing  box  (Fig.  113),  witli 
a  top  of  thin  wood  or  hard  fibre  and  measuring  from  14  to  17  inches  (35 
to  45  cm.),  is  employed.  The  size  of  the  plates  is  marked  upon  its  top, 
in  order  to  correspond  with  the  dimensions  on  the  drawer  of  the  box. 
Over  this  box  are  placed  cross-wires,  which  facilitate  the  accuracy  of 
superposition.  It  is  advisable  to  have  a  horizontal  bar  scaled  in  inches 
and  centimetres.  The  skiagrapher  should  first  centre  the  object  and  then 
move  the  tube  to  the  right,  corresponding  to  the  vision  of  the  right  eye, 
one  and  one-quarter  inches,  or  3  cm.,  and  procure  a  picture.  Place 
another  plate  in  the  drawer  of  the  box  without  moving  the  object,  and 
adjust  the  tube  to  the  left,  corresponding  to  the  view  of  the  left  eye,  and 
again  take  a  picture.  The  plates  should  be  marked  "  right"  and  "left," 
to  obviate  confusion  after  photographing  the  part. 

Some  operators  use  two  Crookes  tubes  at  a  distance  (the  anodes)  of 
seven  or  eight  centimetres,  not  moving  the  tube  at  each  exposure.  The 
objection  to  this  method  is,  that  the  two  tubes  will  have  different  de- 
grees of  vacuum. 

A.  B.  Johnson,  of  New  York,  and  P.  Czermak  prefer  to  shift  the 
box  two  and  one-half  inches  instead  of  sliding  the  tul>e. 

Another  method  of  taking  stereoscopic  pictures2  is  to  have  a  plate- 
holder  so  constructed  that,  by  a  heavy  sheet  of  metal,  one-half  the  <  «>n 
tained  photographic  plate  is  shielded  from  the  action  of  the  rays.     After 

'Electrical  Review,  November  16,  1901. 

J  A.  B.  Johnson,  Annals  of  Surgery,  April,  1902. 


FIG.  112. 


246 


EaJSCTEO-THEBAPBUTICS. 


exposing  one-half  the  plate,  the  other  halt'  is  brought  beneath  the  part. 
the  latter  having  been  previously  shielded  by  a  lead  screen.  The  tnl>e 
is  moved  a  suitable  distance,  and  a  second  exposure  is  made.  The 


FIG.  113.— Author's  plate-changing  box. 

two  pictures  thus  lie  side  by  side  upon  the  same  plate,  and  may  be 
copied  in  a  reduced  size,  and  viewed  as  positives  on  glass  or  paper  in  a 
refracting  stereoscope.  This  method  is  suited  for  the  extremities,  l»ut 
not  for  the  chest,  abdomen,  etc. 

Marie  and  Ribaut1  have  derived  the  following  formulae  and  table, 
which  they  assert  will  give  the  most  relief  and  perspective  view  without 
fatiguing  the  operator's  eyes.  They  arrived  at  these  deduced  results  by 
a  series  of  experiments  founded  upon  mathematical  proofs: 

A  Maximum  =  The  maximum  displacement  of  focus  tube. 

1)  The  distance  of  the  tube  from  the  surface  of  the  object. 

P     —    The  thickness  of  the  object. 

P    (D  +  P) 
Max. 

50  P 

'Archives  d'c-lectricite  medicale  experimentales  et  cliniques,  viii.,  July  15,  1905, 
and  Trait*'-  Radiologie  Medicale  by  Bouchard,  pp.  "><;">  ami  5t;i;. 


THE  PRIXCIPLES  OF  TI-riINK  . 


247 


When  the  actual  size  ("dimension  '  is  desired,  then        i>  equal  to  6.6 
cm. — viz.,  the  distance  between  two  pupils. 


6.6  cm. 


P    (D  4-  P) 
,50  P 


Marie  and  Rlbauf  s  Table,  showing  the  varying  relationships  between 
the  thickness  of  the  part  examined  and  the  displacement  of  the  Crookes 
tube,  and  also  the  change  in  the  distance  of  the  tube  from  the  surface 
of  the  object.  For  example,  if  the  part,  such  as  the  wrist,  is  6  cm.  in 
thickness  and  the  distance  of  the  tube  is  40  cm.,  then  the  displacement 
of  the  tube  will  be  equal  to  6.1  cm. 


P  =  THICKNESS 

UK    THE    OBJECT. 


\>       DISTANCE  OF  THE  TI'BE  FROM  THE  SURFACE  OF  THE  OBJECT. 


Inch. 

Cm. 

8          20 
Inch.    Cm. 

12 
Inch. 

30 
Cm. 

Inch 

40 
Cm. 

Inch. 

50 
Cm. 

23f 
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60 

Cm. 

MAXIMTM 

DISPLACEMENT   OF   CuoOKES   Tl'BE. 

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I  have;  devised  a  special  table  and  an  adjustable  plate-holder,  which 
I  believe  possess  many  advantages. 

The  table  is  so  constructed  that  the  tube  can  be  made  to  slide 
on  a  rod  with  great  ease,  whether  on  the  top,  bottom,  or  side,  without 
discomfort  to  the  patient. 

Usually  in  skiagraphing  for  either  simple  or  stereoscopic  purposes 
the  part  is  placed  over  the  table  or  plate -changing  box,  and  the  weight 
of  the  patient  rests  upon  the  plate,  thus  changing  the  original  position  of 
the  foreign  body.  "With  the  above  device,  the  part  maybe  placed  in  a 
natural  position,  without  the  plate-changing  frame  touching  it  at  any 
point. 

To  produce  two  negatives  of  "equal  density"  the  degree  of  penetra- 
tion of  the  rays  should  be  as  nearly  uniform  as  possible,  and  great  care 
should  be  exercised  in  development. 


IMS 


ELECTBO-THEB  A I » K r TI ( 'S. 


Xo  two  tubes  have  exactly  the  some  degree  of  vacuniu,  the  same 
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judge  the  time  of  exposure  of  the  second  plate  by  experience.  A  self- 
regulating  tube  is  pivfcralilc.  I  usually  give  a  little  longer  time  for  the 
second  exposure  than  for  the  first,  as  the  tube  runs  down  a  little  and  the 
penetration  lessens.  Short  exposures  are  most  desirable. 


THE  PRINCIPLES  OF  TECHNH1.  240 

Lately  I  have  been  developing  for  the  same  duration  of  time  two  ex- 
posed plates  in  one  tray,  but  I  have  discarded  this  method,  because  the 
handling  of  large  plates  is  difficult  and  the  plates  differ  in  density,  but 
now  I  develop  them  separately,  and  by  carefully  mixing  the  developer 
before  and  during  the  progress  of  development,  I  alter  it  as  the  plate 
requires,  to  secure  equal  densities.  Soft  negatives  are  preferable. 

D.  METHODS  OF  VIEWING  STEREO-SKIAGRAMS. 


Reflecting  Method.  —  This  instrument,  devised  in  1838, 
consists  of  two  vertical  mirrors  accurately  set  at  a  right  angle  (the  ver- 
tex of  the  angle  facing  the  middle  line  of  the  observer's  forehead),  this 
arrangement  of  mirrors  slides  forward  and  backward,  and  is  placed  over 
a  long  board,  upon  which  is  a  vertical  frame  parallel  with  the  reflecting 
plane,  forming  an  angle  of  45°.  These  frames  and  mirrors  are  so  con- 
structed that  the  observer  can  easily  superimpose  the  two  pictures. 
(Fig.  114.) 

The  pictures  must  be  so  placed  in  the  frame  as  to  hold  the  same 
position  as  that  occupied  by  the  Crookes  tube  during  exposure.  For 
instance,  the  picture  marked  ''right''  should  be  placed  in  the  frame  to 
the  right  of  the  observer  in  order  to  get  an  anterior  view  of  the  part.  If 
placed  in  the  left-hand  frame,  a  posterior  view  will  be  obtained.  When 
prints  are  examined  with  reflected  light,  by  turning  the  prints  end  for 
end,  without  changing  the  UR"  or  UL''  positions,  posterior  and  anterior 
views  may  be  obtained  ;  this  is  known  as  pseudo-stereoscopy. 

The  advantages  of  Wheatstoue's  reflecting  method  are  that  :  Any 
sized  negative,  even  before  a  print  is  made,  can  be  viewed.  When  nega- 
tives are  used  without  prints,  the  picture  is  seen  more  in  detail  ;  nega- 
tives can  be  examined  while  wet.  I  bore  two  holes  in  a  block  of  wood 
which  is  placed  between  the  reflecting  mirrors,  where  the  same  reflecting 
light  used  for  negatives  can  be  set  for  the  illumination  of  prints. 

Brewster's  refracting  or  lenticular  stereoscope  is  founded  on  the  prin- 
ciple that  two  pictures  can  be  produced,  by  causing  a  displacement  of  the 
tube,  two  and  one  half  inches  (6.5  cm.  ),  with  the  pictures  side  by  side, 
and  viewed  with  two  prisms  (18°)  for  each  eye.  (Fig.  110.) 

These  pictures  will  be  superimposed  according  to  the  laws  of  refrac- 
tion. One  disadvantage  of  the  Brewster  refracting  stereoscope  is  the 
jireat  degree  of  the  convergence  of  the  axis  of  vision  required,  and  the 
necessity  of  reducing  the  size  of  the  pictures  for  use  in  this  refractor. 
This  has  been  overcome  by  Walter,  of  Germany,  who  places  the  original 
si/,-  negative  in  the  frame  and  views  it  with  different  prisms.  (Fig.  115.) 

There  is  yet  another  method  of  viewing  these  stereoscopic  transpar- 
encies or  prints.  The  reduced  pictures  mounted  in  frames  are  placed  on 
an  endless  chain,  and  are  viewed  by  the  operator  who  looks  through  the 


250 


ELECTEO-THEEAPEUTICS. 


prisms.  The  advantages  of  this  method  are  :  That  the  number  of  pic- 
tures is  practically  unlimited,  unnecessary  light  is  excluded,  and  that 
prints  as  well  as  transparencies  may  be  employed. 

Lately  I  have  made  some  plastographic  views  from  these  stereo- 
scopic negatives.  The  plastographic  method  consists  in  superimposing 
one  print  in  green  over  another  in  crimson,  which  offers  a  ha/.incss  to  the 
naked  eye,  but  when  viewed  through  eye-glasses  (one  of  a  green  color 
and  the  other  of  crimson),  a  very  beautiful  picture  with  marked  relief 


Fio.  115.— Prism  stereoscope  of  Walter. 

details  is  afforded.  I  believe  this  process  will  be  useful  for  stereo 
scopically  illustrating  medical  journals  and  scientific  books.  There  is 
another  method  of  combining  stereoscopic  pictures  without  an  instru- 
ment, which  can  easily  be  acquired  by  crossing  the  visual  axes.  Place 
the  skiagraph  in  front,  hold  up  the  index  finger  in  the  middle  line 
between  the  eyes  and  the  skiagrams,  and  while  looking  at  the  top  of 
the  finger,  a  third  picture  will  appear  in  the  centre,  offering  a  most 
iM'autiful  stereoscopic  effect. 

E.  ADVANTAGES  OF  STEREO-SKI  ALL- \IMIV. 

An  ordinary  skiagraph  is  composed  of  superimposed  shadows  of 
dilferent  densities,  which  appear  Hat  on  the  negative  or  print,  and  in  ad- 
dition contains  many  shadows  appearing  indistinct  and  weak,  but  in 
the  stereoscopic  pictures  the  supcrimposition  will  be  more  distinct 
and  visible.  Two  plates  exposed  at  different  angles  are  used,  and  any 
deficiency  in  one  is  easily  compensated  tor  in  the  other.  Another 


FIG.  114.— Wheatstone's  reflecting  stereoscope,  as  modified  by  Weigel. 


FIG.  116.— Stereo-skiagram  of  Colles's  fracture,  palmar  view  taken  through  the  splint,  and  should  be  viewed 

with  prism  stereoscope. 


THE  PRINCIPLES  OF  TEC1IXH  .  •_>.->  l 

advantage  is  that  the  anterior  and  tin-  posterior  views  are  discernible. 
In  passing,  we  will  very  briefly  note  a  few  of  the  many  applications 
of  siereo-skiagraphy. 

Anatomy. — For  demonstrating  the  structure  of  the  bones.  In  the 
long  and  short  bones  the  trabecuhe  are  seen,  and  in  the  long  bones  we 
may  observe  the  lamella?  in  the  shafts  and  in  the  cancellous  tissue. 

The  spiral  arrangement  of  the  lamelhe  is  distinctly  shown,  especially 
in  the  humerus  and  femur,  also  its  change  in  direction  near  the  articular 
surfaces. 

In  examining  the  skull,  the  grooves  for  the  meniugeal  arteries  are 
seen,  the  concave  appearance  of  the  cranial  processes,  the  frontal  sinuses, 
the  antrum  of  Highmore,  the  turbinated  bones,  etc. 

In  studying  the  mechanism  of  the  joints,  these  pictures  give  a  per- 
spective of  the  relations  of  the  articular  surfaces  of  the  bones,  their  actual 
depths,  and  the  relation  of  the  processes,  to  the  observer. 

Arteries,  veins,  bronchi,  and  excretory  ducts,  wheu  injected  with 
opaque  materials,  such  as  lead  or  mercury,  show  their  exact  relations 
(their  depths)  to  the  bones,  the  muscles,  etc. 

Surgery. — Of  the  numerous  methods  of  locating  foreign  bodies  stereo- 
skiagraphy  is  the  most  satisfactory,  because  it  offers  a  definite  view  of 
the  foreign  body,  and  thus  enables  the  surgeon  to  operate  with  cer- 
tainty. The  negatives  should  be  soft  and  full  of  details,  in  order  to  show 
shadows  of  different  tissues,  especially  cystic  and  soft  tumor  tissue. 

When  two  negatives  of  this  kind  are  superimposed,  the  intensity  of 
the  shadow  is  doubled.  I  am  and  have  been  using  this  method  in 
the  Philadelphia  Hospital  in  a  series  of  experiments  for  detecting  and 
locating  brain  tumors,  etc. 

The  foregoing  statement  is  also  true  in  regard  to  fractures.  (Fig. 
116.)  By  this  method  we  may  procure  definite  views  of  the  injuries,  the 
exact  position  of  the  fragments,  the  amount  of  overlapping,  the  separa- 
tion, the  degree  of  apposition  in  deformities,  etc.  The  ordinary  skiagraph 
does  not  show  the  variety  and  character  of  dislocations.  The  stereo-skia- 
graph  overcomes  this  difficulty,  and  enables  one  to  differentiate  between 
an  anterior  and  a  posterior  dislocation.  We  may  view  the  thorax  either 
from  an  anterior  or  posterior  aspect.  The  heart  and  the  aorta  with  their 
various  relations  are  interesting  and  fascinating  from  a  practical  and 
scientific  standpoint.  In  the  study  of  normal  and  morbid  conditions, 
I  invariably  resort  to  the  employment  of  stereo-skiagraphy  at  the 
Philadelphia  Hospital. 


CHAPTER   III 

THE  CLINICAL  APPLICATIONS  OF  THE  KOXTGEX  KAYS. 

INTRODUCTION. 

I.  The  Uses  of  the  X-rays  in  Anatomy  and  Physiology. 

MUCH  has  been  written  about  the  uses  of  the  X-rays  in  investigating 
anatomical  structures  and  in  studying  the  functions  of  organs.  Undoubt- 
edly the  knowledge  gained  by  dissection  and  vivisection  through  many 
years  of  laborious  research  has  been  greatly  altered  and  modified  through 
the  application  of  the  X-rays. 

A.  BLOOD-VESSELS  AND  RESPIRATORY  TRACT. 

I  have  studied  the  blood-vessels  of  infants  and  adults  by  injecting 
into  them  a  substance  opaque  to  the  X-rays.  The  substance  used  is  a 
concentrated  emulsion  of  bismuth  subnitrate,  a  strong  solution  of  litharge 
(red  oxide  of  lead),  or  metallic  mercury.  In  order  to  demonstrate 
sharply  the  arterial  tree,  the  injection  must  be  done  carefully  and  slowly. 
By  some  it  is  deemed  advisable  first  to  empty  the  arterial  system  of  all 
its  blood,  and  then  to  inject  a  solution  of  zinc  chloride,  so  as  to  get  rid  of 
any  existing  clots.  This  solution  should  be  removed  by  washing,  or  by 
forcing  water  into  the  arterial  system,  followed  by  an  injection  of  metallic 
mercury,  by  a  force  pump  connected  to  the  external  carotid  artery. 

The  kidney,  heart,  brain,  spleen,  liver,  stomach,  etc.,  may  have 
their  arterial  systems  demonstrated  by  first  removing  them  from  the 
cadaver,  and  then  injecting  into  them  some  opaque  substance,  preferably 
lead  oxide.  In  experiments  performed  two  years  ago,  I  showed  the 
arterial  and  venous  systems  of  a  kidney  by  employing  substances  of 
different  densities.  Thus  metallic  mercury  was  used  for  the  renal  artery 
and  its  branches,  and  a  weak  solution  of  red  oxide  of  lead  for  the  renal 
vein  and  its  tributaries. 

The  brachial,  radial,  and  popliteal  arteries  have  been  observed  in 
the  living  subject,  especially  in  the  aged  where  sclerosis  was  present. 

I  have  traced  the  respiratory  tract  from  the  larynx  to  the  small 
bronchioles,  by  introducing  into  the  upper  opening  of  the  larynx  a  solu- 
tion of  red  oxide  of  lead  and  allowing  it  to  expand  the  air-vesicles. 
The  larynx,  the  trachea  with  its  bifurcation,  and  the  bronchi,  with  a  few 
of  its  branches,  can  be  beaut  i fully  demonstrated  skiagraphically.  1  nstead 
of  the  red  oxide  of  lead,  I  have  used  small  shot,  which  travel  only  to  the 
smaller  bronchioles,  and  not  into  the  respiratory  passages  and  air-cells. 
252 


THE  CLINICAL  APPLICATIONS. 


253 


B.  BOXES  AND  JOINTS. 

So  far  as  the  subject  of  anatomy  is  concerned,  the  X-rays  have  been 
most  useful  in  studying  the  osseous  system,  \\~heu  the  entire  foetal 
skeletal  system  is  mapped  out  in  cartilage,  the  X-rays  cast  no  shadows 
of  these  structures.  As  soon  as  ossification  of  the  cartilaginous  tissues 
begins  and  advances,  every  step  involved  in  the  process  may  be  shown 
by  X-ray  skiagrams.  The  cartilage,  being  transparent  to  the  rays,  casts 
no  shadow. 

The  rays  are  of  great  value  in  estimating  and  detecting  delayed 
union  of  the  epiphyses.  All  X-ray  specialists  should  be  thoroughly 
familiar  with  the  normal  appearance  of  an  epiphysis  and  the  time  of 
union.  Mr.  Poland,  F.R.C.S.,1  London,  states,  that  epiphyseal  separa- 
tion is  much  more  common  in  males,  owing  to  their  rougher  forms  of 
amusement,  heavier  work,  etc.,  and  also  that  the  injury  is  frequently 
started  in  intra-uterine  life  or  during  awkward,  difficult,  and  instru- 
mental labors.  The  larger  number  of  injuries  are  produced  during 
childhood,  between  the  ages  of  five  and  ten  and  even  up  to  the  sixteenth 
year  of  life. 

The  most  frequent  seats  of  epiphyseal  lesions  occur  in  the  upper 
epiphysis  of  the  humerus,  lower  epiphysis  of  the  femur,  lower  epiphysis 
of  the  radius,  and  in  the  phalangeal  and  metacarpal  and  metatarsal 
epiphyses.  The  times  of  union  of  the  various  epiphyses  to  the  corre- 
sponding diaphyses  of  long  bones  are  as  follows: 


UPPEK  EXTREMITY. 
Radius 
Radius 
Ulna 
Ulna 
Hurnerus 
Humerus 
Humerus 
Motacarpal 
Phalanges  (fingers) 
Clavicle 

LOWER  EXTREMITY. 
Tibia 
Tibia 
Fibula 
Fibula 
Femur 
Femur 
Femur 


(upper  end) 

(lower  end) 

(end  of  olecranon) 

(lower  end) 

(lower  end) 

(upper  end) 

(end  of  epicondyle) 


(upper  end) 
( lower  end ) 
(upper  end) 
(lower  end) 
(lesser  trochanter) 
(greater  trochanter) 
(head) 


Between 
Between 
Between 
Between 
Between 
Between 
Between 
Between 
Between 
Between 


Between 
Between 
Between 
Between 
Between 
Between 
Between 


15  and  17. 

17  and  19. 

15  and  17. 

18  and  21. 

16  and  17. 

18  and  22. 

17  and  18. 

19  and  21. 

18  and  20. 
22  and  26. 


21  and  22. 

18  and  19. 
20  and  22. 

19  and  22. 

17  and  19. 

18  and  19. 
18  and  20. 


1 "  Traumatic    Separation    of    the    Epiphyses.' 
Smith,  Elder  &  Co.,  London,  1898. 


A  monograph    published  by 


\-AA-A  T  IK  >-T  1  1  1  :  i  ;  A  i  •  1-:  i'T  i  (  \s. 

LO\VKK  EXTREMITY.  —  '  nntin<i"l. 


(lower  end)  Between  L'O  and  24. 

Mftatarsal  lietween  19  and  21. 

Phalanges  (toes)  Between  17  and  1M. 

(  Ilium  Between    7  and  10. 

Isrhium  Between    7  and  12. 

]    Pul.is  Between    .i  and  15. 
(   (Uniting  at  25) 

As  an  epiphysis  consists  of  rapidly  developing  cartilage,  it  is  readily 
penetrable  by  the  rays,  while  a  skiagram  casts  a  light  shadow  of  the 
epiphyseal  band,  which  on  the  negative  appeal's  as  a  dark  band.  It  is 
essential  to  diagnose  correctly  an  epiphyseal  injury,  as  it  often  results  in 
severe  deformity.  Both  sides  must  be  taken  for  comparison. 

The  joints  and  their  mechanism  have  been  carefully  studied  by  Dr. 
Ernest  A.  Codmau,1  of  Boston.  He  says  :  "This  has  been  undertaken 
in  two  ways,  —  first,  by  skiagraphiug  the  normal  joints  in  their  extreme 
positions  (extreme  flexion,  extension,  adduction,  etc.)  ;  secondly.  l>y 
watching  the  movements  with  the  fluoroscope.  As  the  parts  of  the  object 
near  the  plate  show  best,  it  is  necessary  to  take  each  position  from 
both  sides.  One  thing  which  will  arrest  attention  is  the  great  distance 
that  apparently  intervenes  between  the  bones.  This  is  in  part  due  to 
the  fact  that  the  articular  cartilages,  being  easily  traversed  by  the 
rays,  do  not  cast  a  shadow.  The  wrist  -joint  has  proved  most  interest- 
ing in  this  study,  and  the  points  brought  out  will  be  found  in  the  fol- 
lowing description.  For  convenience  we  may  consider  the  wrist-joint  to 
lie  made  up  of  four  immobile  and  two  mobile  elements.  (1)  Immobile 
(/.  <".,  those  made  up  of  simple  bones  or  of  a  group  of  bones,  the  com- 
ponents of  which  cannot  change  relative  positions).  These  are  :  (a) 
metacarpal  of  thumb,  (6)  metacarpal  of  ring-finger,  (c)  metacarpal  of 
index  and  middle  finger,  with  trapezium,  trapezoid,  os  magnum,  audunci- 
form.  This  last  group  is  so  firmly  attached  to  one  another  that  they  move 
as  a  whole,  practically  as  one  bone.  No  doubt,  however,  their  li-a 
mentous  attachments  allow  of  more  or  less  spring  in  strained  positions  of 
the  hand  brought  about  by  external  force. 

"2.  Mobile  (the  components  of  which  change  relative  positions). 
(«)  The  intermediate  row  of  carpal  bones  composed  of  scaphoid,  semi- 
lunar.  cuneiform,  and  pisiform.  (6)  Radius  and  ulna.  From  skiagraphs 
it  is  found  that  the  carpus  and  metacarpus  are,  in  any  of  the  extreme 
positions,  in  practically  the  same  relation  to  the  radius,  no  matter  what 
the  relation  of  the  radius  to  the  ulna,  whether  prouation  or  supination. 
This  is  due  to  the  more  or  less  flexible  fibro-  cartilage,  which  in  any  posi- 
tion completes  the  cups  of  the  radial  joint.  The  question  of  mechanism, 
then,  is  further  simplified  by  leaving  out  the  ulna,  which  really  does  not 

1  Archives  of  the  Koiitgen  Ray,  AiijruM. 


THE  CLINICAL  A  PPLK  'ATIOXS.  255 

enter  into  the  construction  of  the  joint  except  as  a  pivot.  The  pisiform 
also  does  not  enter  the  mechanism,  serving  only  as  a  sesamoid  for  the 
nlnar  tendons. 

••  Proceeding  to  eliminate  other  accessory  elements,  \ve  can  disregard 
the  metaearpal  of  the  thumb,  ring  and  index  fingers,  each  of  which 
moves  independently  on  the  large  fixed  elements  composed  of  the  os  mag- 
num, etc.  The  thumb  forms  a  typical  saddle  joint  with  the  trapezium, 
with  the  pommels  of  the  saddle  so  low  that  motion  is  allowed  iu  a  small 
circle,  either  as  rotation  within  the  circumference  or  straight  motions  on 
any  of  the  radii.  The  metaearpal  of  the  ring  finger  is  allowed  a  slight 
antero-posterior  motion  of  a  few  degrees;  that  of  the  little  finger  the 
same,  but  of  slightly  greater  extent,  with  possibly  a  degree  of  adduction. 
This  leaves  us  with  :  (a)  The  large  compound  fixed  element  of  the  os 
magnum,  etc.  (6)  The  radius  with  fibro-cartilage.  (c)  The  intermediate 
element  of  the  scaphoid,  semilunar,  and  cuneiform.  These  constitute  the 
real  wrist -joint. 

"By  injecting  a  solution  of  paraffin  in  alcohol  containing  substances 
opaque  to  the  rays,  we  may  bring  out  the  normal  anatomical  relations  of 
certain  of  the  internal  organs.  Thus,  by  injecting  this  charged  solution 
into  the  urethra,  bladder  and  ureters,  vagina,  Fallopian  tubes,  rectum, 
and  the  intestines,  we  may  be  able  to  produce  exact  skiagrams.  To  bring 
out  the  normal  topography  of  the  large  intestines,  inject  with  water, 
and  allow  it  to  escape  from  the  small  intestines  through  an  incision  previ- 
ously made  ;  this  will  remove  the  fecal  matter,  permitting  the  opaque 
solution  to  fill  all  crevices  or  depressions  between  the  rugae.  As  has  been 
previously  stated,  we  may  by  the  X-rays  determine  the  movements  of  the 
heart  in  the  living.  The  heaving  of  the  diaphragm,  together  with  the 
relationship  this  organ  bears  to  the  movements  of  the  pulsating  heart, 
may  be  illustrated  by  careful  fluorescent  screen  examinations." 

M.  Bouchard1  reports  that  he  observed  a  marked  dilatation  of  the 
left  auricle  when  the  intra-thoracic  blood  pressure  was  raised  during  a 
deep  and  prolonged  inspiration.  The  same  condition  exists  when  the 
inspirations  of  a  whooping-cough  paroxysm  are  most  violent.  In  two 
cases  examined  with  the  fluorescent  screen  I  was  enabled  to  observe  the 
same  condition.  During  forced  inspiration  a  clear  space  between  the 
diaphragm  and  the  heart  may  readily  be  demonstrated  that  does  not  exist 
during  ordinary  inspiration. 

C.  PHYSIOLOGY  OF  PHONATION. 

The  physiology  of  phonation  as  seen  by  careful  screen  examinations 
is  very  interesting.  Max  Scheier2  was  the  first  to  investigate  this  subject. 

1  Lancet,  September  10,  1898. 

-  Fortechritte  a.  <1.  Geb.  d.  Rf.ntgenstr. ,  B.  i.,  1897-1898. 


256  ELBCTBO-THEEAPEUTIC8. 

In  examining  the  parts  involved  during  phonation.  the  X-rays  should 
penetrate  the  head  laterally,  the  screen  showing  clear  shadows  of  the 
upper  part  of  the  pharynx  and  the  naso-pharyngeal  space.  If  the  person 
under  examination  utters  a  vowel  sound,  the  screen  shows  the  velum  to 
be  raised,  taking  a  position  in  the  naso-pharyngeal  space,  the  position  vary 
ing  with  the  sound  that  is  uttered.  During  the  rendition  of  the  vowel 
letter  a,  we  may  observe  the  velum  to  rise  a  little  and  become  more  and 
more  elevated  as  the  other  vowels  (in  the  order  of  e,  o,  u,  and  i)  are  suc- 
cessively uttered.  In  high  tones  the  velum  rises  more  than  when  low 
ones  are  uttered. 

If  consonants  (except  resonauts  and  semi-vowels)  are  pronounced, 
the  velum  is  raised  higher  than  when  the  sound  i  is  uttered.  If  the  sounds 
of  the  letters  m,  u,  and  ing  are  uttered,  the  velum  rises  only  a  very  little 
and  in  many  cases  not  at  all.  The  movements  and  positions  of  the  tongue, 
lips,  and  the  inferior  maxillary  bone  can  also  be  easily  interpreted  on  the 
screen.  The  movements  of  the  larynx,  velum,  and  other  associated  parts 
can  easily  be  seen  during  deglutition,  breathing,  hawking,  and  sneezing. 

II.  Diagnostic    Value     in    Fractures,    Dislocations,    and     Callus 
Formation. 

The  employment  of  the  X-rays  in  surgery  has  found  a  fertile  field  iu 
the  study  of  fractures,  their  frequency,  character,  and  varieties.  Only  of 
late  empirical  knowledge  has  given  way  to  scientific  deductions,  whilst 
improved  and  modified  forms  of  treatment  have  followed  in  the  wake  of 
this  recent  achievement. 

The  deformity  associated  with  a  fracture  is  often  deceptive.  It  may 
be  due  to  swelling  of  the  neighboring  tissues,  occurring  at  the  time  of 
or  subsequent  to  the  accident.  The  diagnosis  of  a  fracture  is  not  pre- 
cluded by  employing  certain  bony  landmarks  as  guides  in  the  diagnosis. 
Again,  shortening  does  not  occur  in  green-stick  fractures,  in  those  which 
are  impacted,  or  in  the  iutra-articular  or  in  the  longitudinal  fractures  of 
small  bones,  such  as  the  carpal  or  tarsal. 

Preternatural  mobility  is  a  sign  of  doubtful  value.  It  often  defies 
recognition  in  incomplete,  iutra-articular,  and  fissured  fractures.  In 
fractures  near  a  joint  it  is  often  impossible  to  declare  positively  if  the 
mobility  proceed  from  the  joint  or  from  the  supposed  seat  of  fracture. 
Difficulty  may  be  experienced  in  grasping  the  fragments,  and  rough 
manipulat  ion  exposes  the  patient  to  the  danger  of  having  a  simple  fracture 
converted  into  a  compound  one. 

Crepitus  is  likewise  an  unreliable  guide  in  the  diagnosis  of  fracture. 
Interposition  between  the  fragments  of  muscle  tissue,  fascia,  or  granula- 
tions will  ma.sk  the  true  condition.  In  incomplete,  fissured,  or  impacted 
fractures  of  the  neck  of  the  femur  and  humerus,  the  nature  and  seat  of  the 


THE  CLINICAL  APPLICATIONS.  257 

injury  may  fail  to  elicit  this  sign  :  again  this  difficulty  may  be  encountered 
where  muscular  action  maintains  displacement  and  separation  of  the 
fragments,  as  iu  transverse  fracture  of  the  patella.  «>lecran»»n.  coracoid 
and  acroinion  processes  of  the  scapula,  etc.  Lastly,  tenosynovitis.  move- 
ment of  a  rheumatic  joint,  and  inflammation  of  a  sheath  or  tendon  may 
closely  simulate  crepitus. 

Movement  of  a  broken  bone  or  pressure  at  the  seat  of  fracture  elicits 
pain,  but  its  presence  is  not  positively  diagnostic.  Loss  of  function  is 
another  negative  proof,  as  arthritis  and  painful  joints  will  often  cause 
this  condition. 

A.  THE  ADVANTAGES  OF  THE  BONTGEN  RAY  METHOD  IN  THE  DIFFER- 
ENTIAL DIAGNOSIS  OF  COMPLICATED  FRACTURES. 

The  foregoing  signs  and  symptoms  are  established  facts  based  on 
clinical  knowledge.  They,  however,  do  not  manifest  themselves  in  any 
given  order,  and  are  not  typical,  as  they  do  not  exist  in  all  cases.  They 
always  require  an  observant  eye,  a  trained  ear,  and  an  experienced  touch. 
This  method  is  supplemented  by  the  X-rays,  which  for  accuracy  and 
reliability  are  far  superior  to  it,  and  possess  the  following  additional 
advantages : 

1.  As  a  method  of  diagnosis  it  is  painless.     It  entails  no  waiting  for 
the  diminution  of  the  swelling  nor  necessity  for  the  removal  of  bandages. 

2.  It  allows  a  positive  diagnosis  to  be  made,  at  the  same  time  reveal- 
ing the  exact  nature  of  the  injury. 

The  variety  of  fracture,  whether  oblique,  transverse,  comminuted  or 
fissured. 

Its  exact  seat  and  extent,  whether  of  the  anatomical  or  surgical 
neck  or  shaft,  whether  intra-  or  extra-capsular,  simple,  complete,  or 
incomplete,  green-stick  or  intra-articular,  etc. 

The  number  of  fragments,  their  size,  shape,  position  or  location. 

The  overlapping  of  the  fragments,  the  exact  amount  and  direction 
of  displacement,  and  whether  the  fragments  are  in  apposition  or  not, 
can  only  be  ascertained  before  or  after  the  reduction  of  the  fracture. 

3.  It  allows  of  its  differential  diagnosis  from  the  following  condi- 
tions :  dislocation,  epiphyseal  separation  and  displacement ;  diseases  of 
bones  and  joints. 

The  differentiation  of  a  fracture  from  a  dislocation  is  often  difficult, 
because  the  great  effusion  or  swelling  around  the  joint  will  quickly 
produce  marked  deformity.  Because  immediate  reduction  is  necessary, 
an  early  diagnosis  is  an  important  matter. 

When  an  injury  occurs  in  the  vicinity  of  a  joint,  especially  in  chil- 
dren, the  epiphyseal  condition  will  at  once  attract  attention.  The 
epiphyseal  separation  or  displacement  is  most  important,  but  is  easily 


258  ELECTKO-THEKAPKI'TICS. 


by  the  skiagraph.  lu  differentiating  epiphyseal  separation  from 
tincture,  the  patient's  age  must  be  considered,  tlie  average  date  of  union 
varying  in  each  individual. 

Fractures  of  the  epiphyses  and  their  displacements  can  also  be 
differentiated  from  fractures  of  other  portions  of  the  bone.  Fragments 
of  the  epiphyses  may  float  in  the  joint  and  simulate  fracture  or  dislo- 
cation. 

B.  DISEASES  OF  BONES  AND  JOINTS. 

The  normal  bone  appears  on  the  skiagram  with  its  characteristic 
texture.  When  any  alteration,  as  increased  density,  is  shown,  it  is  due 
either  to  an  increased  blood  supply  (as  in  osteitis  or  periostitis)  or  to 
hypertrophy  of  the  osseous  structure,  and  the  beginning  of  an  inflamma- 
tory process.  Later,  when  the  caseation  or  absorption  takes  place, 
the  bone  will  appear  more  translucent  than  normal.  This  shadow  can 
readily  be  differentiated  from  that  of  a  fracture. 

Osteiti*  <in<l  periostitis  are  differentiated  from  fracture  and  callus  with 
great  facility. 

Tumors  of  bones  can  be  differentiated  from  suspected  fractures  or 
formations  of  callus,  especially  in  cases  of  impacted  fractures  of  the  neck 
of  the  femur;  for  the  latter,  being  undiaguosed,  and  exuberant  callus 
forming,  may  be  mistaken  for  a  tumor. 

Exostoses  of  bones,  which  may  occur  either  after  fracture  or  in- 
jury to  the  epiphyses,  can  be  differentiated  from  a  displaced  fragment 
of  fractured  bone.  Exostoses,  however,  may  be  congenital,  when  not 
infrequently  they  are  found  to  be  multiple. 

The  differentiation  between  coxa  vara,  fracture  of  the  neck  of  the 
femur,  coxalgia,  and  arthritis  of  the  hip-joint,  is  of  great  value  to  the 
surgeon. 

Diseases  of  Joints.  —  In  cases  of  synovitis,  tenosynovitis,  arthralgia, 
rheumatic  conditions,  bursitis,  epiphysitis,  and  tuberculous  arthritis 
following  injuries,  the  X-rays  will  prove  most  valuable  in  clearing  up  the 
diagnosis  by  differentiating  between  fractures  and  diseases  or  injuries 
of  the  soft  tissues. 

By  means  of  the  X-rays  we  are  enabled  to  show  clearly  the  bones,  the 
muscles,  and  tendons  (such  as  tendo  Achillis,  and  ligament  um  patelke, 
tendo-qitadrioeps,  etc.)  ;  but  often  we  experience  much  difficulty  in  de- 
tect ing  with  the  aid  of  the  X-rays  the  injuries  to  these  soft  structures  in 
all  parts  of  the  human  body.  In  children  the  X-rays  show  the  capsule 
and  hamstring  tendons  in  the  knee-joints,  etc. 

Sprain.*  <ni(l  drain*  caused  by  a  twisting  of  the  joint,  which  result  in 
a  rupture  of  some  or  all  of  the  ligaments  or  tendons,  are  conditions  always 
difficult  to  diagnose.  In  those  suspected  cases  when  the  part  is  examined 


THE  CLINICAL  APPLICATIONS. 

with  the  X-rays  it  is  noticed  that  there  is  no  fracture,  and  by  exclusion 
we  are  justified  in  saying  that  a  sprain  exists.  If  the  periosteum  is  torn 
off  by  a  ligament  or  tendon,  it  will  be  observed  under  certain  favor- 
able conditions.  (See  Figs.  133  and  145.) 

In  many  instances  I  have  been  able  to  see  on  the  negative  the  ten- 
dons and  ligaments  in  the  ankle-joint,  and  in  the  lateral  view  also  those 
of  the  knee-joint,  etc.,  especially  when  a  soft  negative  was  obtained.  In 
children  the  negative  should  be  "soft"  and  full  of  details  ;  a  short 
exposure  with  a  high-vacuum  tube  should  be  the  rule. 

C.  VALUE  IN  THE  TREATMENT  OF  FRACTURES. 

The  X-ray  diagnosis  during  and  after  the  treatment  of  fractures  is 
invaluable,  assisting  the  surgeon  in  approximating  the  fragments,  which 
can  be  accomplished  by  observing  the  process  with  a  fluoroscope  ;  thus  a 
cast  can  be  applied  at  once  without  disturbing  the  reduced  fragments. 
After  the  permanent  dressing  or  cast  has  been  applied,  another  fluoro- 
scopic  or  skiagraphic  examination  will  reassure  him  of  the  correctness  of 
the  position  of  the  fragments. 

As  a  fracture  is  readily  diagnosed  by  the  X-rays,  it  is  no  longer 
necessary  to  delay  treatment  until  the  swelling  and  effusion  subside,  thus 
endangering  the  integrity  of  the  joint. 

The  frequency  of  deformities  following  fractures  has  been  steadily 
decreasing  since  the  introduction  of  the  X-rays. 

In  suturing  or  wiring  the  great  advantage  gained  from  the  rays  is 
that  the  operator  is  informed  whether  or  not  the  suturing  material  is 
remaining  intact. 

D.  CALLUS  FORMATION. 

In  the  first  stage  of  callus  formation  the  X-rays  reveal  nothing. 
About  the  twelfth  or  fifteenth  day,  it  manifests  itself  as  a  cloudy  mass  at 
the  ends  of  the  fragments,  and,  as  calcareous  salts  are  deposited,  the  X-rays 
show  the  presence  of  a  dauker  substance.  The  time  required  to  produce 
this  phenomenon  depends  upon  the  variety  of  fracture,  the  age  of  the 
individual  suffering  from  the  accident,  etc. 

Duration  of  Callus  Formation. — This  is  variable,  in  small  bones  the 
time  required  is  brief;  thus  the  metatarsal  bones  manifest  a  cloudy 
appearance  about  the  end  of  the  second  week.  About  the  second  month 
the  rays  show  the  callus  formation  to  be  firm  and  definite.  It  is  fre- 
quently difficult  to  see  the  shadow  of  callus  ;  because  the  latter  is  liable  to- 
be  superimposed  by  the  shadow  of  the  bones.  The  shape  of  the  callus  is 
fusiform  and  encircles  the  ends  of  the  fragments. 

The  Varieties  of  Callm. — In  many  cases  the  bones  are  united  firmly 
and  strongly  several  months  after  the  accident,  nevertheless  the  X-rays 
may  fail  to  reveal  these  conditions.  On  the  contrary,  callus  may  be 


260  ELECTRO-THERAPEUTICS. 

thrown  out  and  yet  the  parts  may  not  !>•'  firmly  united,  as  in  an  oblique 
fracture  of  the  tibia  and  fibula.  This  may  arise  from  the  callus  being 
too  deficient  in  quantity  to  give  a  shadow  on  the  plate. 

I'' T feet  Apposition. — If  there  is  good  apposition  at  the  ends  of  the 
fragments,  especially  of  the  long  bones,  the  callus  is  not  easily  discovered, 
being  overlapped  by  the  shadow  of  the  bones  ;  but  a  careful  examination 
will  divulge  the  callus,  encircling  and  forming  a  faint  fusiform  shadow, 
in  addition  to  the  compact  osseous  tissue. 

Slight  Overlapping. — In  cases  of  displacement  or  slight  overlapping, 
the  space  between  the  fragments  will  be  a  light  area,  but  as  callus 
is  deposited  the  space  will  become  gradually  lighter  on  the  negative, 
depending  upon  the  thickness  of  the  callus  thrown  out. 

False  Joint. — If  callus  does  not  fill  the  space  between  the  fragments, 
the  bone  at  the  seat  of  fracture  remains  movable  and  the  condition  of  a 
false  joint  is  produced.  This  is  the  result  of  a  fibrous  and  not  of  a  bony 
union.  It  is  of  great  importance  to  be  able  to  differentiate  true  from  false 
union. 

Fractures  icith  Extensive  Displacements. — When  the  displacement  is 
so  extensive  (2-3  cm.)  that  the  ends  of  the  fragments  do  not  come  in 
apposition,  lateral  union  occurs,  which  requires  several  years  for  its  com- 
pletion and  at  best  does  not  result  in  a  very  strong  coaptation  of  the 
fragments. 

Age. — Because  of  the  vitality  of  the  osseous  system  and  the  perios- 
teum, the  formation  of  callus  in  children  and  the  adolescent  is  more  rapid 
than  in  the  adult  and  the  aged.  This  ready  deposit  of  callus  must  not 
be  mistaken  for  periostitis  the  result  of  the  traumatism. 

Structure  of  Callus. — When  the  fracture  is  old  and  vicious  union 
has  occurred,  the  X-rays  may  reveal  a  partial  or  complete  absence  of  the 
bony  structure,  the  texture  and  trabeculse  having  suffered  a  complete 
change.  Care  should  be  exercised  not  to  confound  this  osseous  change 
with  osteo-myelitis  or  some  other  bone  disease. 

III.  Fractures  and  Dislocations  of  the  Upper  Extremity. 
THE  HAND. 

Fluoroscopic  Examination. — The  fluoroscopic  examination  of  the  hand 
is  satisfactory  only  when  no  skiagraph  can  be  taken. 

In  the  examination  for  fracture,  the  patient  should  be  seated  and  all 
bandages  and  splints  removed.  In  the  presence  of  a  wound,  avoid  all 
danger  of  sepsis  by  covering  it  with  aseptic  gauze.  Extend  the  hand, 
place  it  against  the  screen,  20  inches  from  the  Crookes  tube,  the  rays  arc 
to  fall  perpendicularly.  The  right  hand  of  the  operator  grasps  the  handle 
of  the  fluoroscope,  with  his  left  he  manipulates  the  hand  of  the  patient, 
gently  pressing  and  rotating  the  suspected  parts  in  order  to  view  at 
all  angles  the  injured  part.  This  pressure  in  cases  of  green-stick  and 


THE  CLINICAL  APPLICATIONS.  261 

impacted  fracture  is  especially  necessary,  in  order  to  produce  marked 
separation  of  the  fi auinents,  so  as  to  be  able  to  view  the  disturbance  of 
texture  and  the  irregular  contour  of  the  periosteum. 

In  order  to  determine  the  direction  of  the  displacement  in  disloca- 
tion, the  phalanges,  carpals,  and  metacarpals  must  be  examined  in  the 
lateral,  antero-posterior,  and  oblique  positions.  The  backward  disloca- 
tion of  the  first  phalanx  of  the  thumb  is  of  special  interest,  because  there 
is  usually  some  difficulty  in  its  reduction.  (Fig.  117.)  Of  course  the 
normal  hand  must  first  be  studied.  (Fig.  118.) 

Skiagraphic  Examination. — Secure  a  sensitive  plate  of  sufficient  size 
to  include  the  entire  hand.  The  arm  and  elbow  should  rest  upon  the 
table,  to  obviate  any  possible  movement  or  tremor.  Place  a  sheet  of 
blotting  paper  or  celluloid  between  the  hand  and  the  plate,  to  prevent 
moisture  affecting  the  gelatine  coat  of  the  latter.  The  tube  should 
now  be  placed  20  inches  (50  cm.)  above  the  hand,  directly  over  the 
middle  of  the  third  metacarpal  bone.  Expose  the  plate  from  3  to  5 
seconds.  In  skiagraphing  the  phalanges,  it  is  necessary  to  take  both  a 
lateral  and  an  antero-posterior  view.  Fracture  of  the  scaphoid  is  shown 
in  Fig.  119. 

Lateral  and  oblique  fractures  of  any  of  the  phalanges  may  be  readily 
skiagraphed  by  placing  the  fingers  separately  in  a  lateral  position  upon 
the  plate.  Unfortunately  carpal  and  metacarpal  bones  cannot  be  skia- 
graphed separately.  The  fluoroscope  usually  suffices  in  the  examina- 
tion of  the  phalanges,  but  for  the  carpal  and  metacarpal  bones  more 
satisfactory  results  are  obtained  with  the  skiagraph.  If  there  is  much 
swelling  of  the  palmar  surface  of  the  hand,  place  that  member  in  the 
dorsal  position  upon  the  plate,  when  the  shadow  of  the  bone  will  appear 
much  clearer. 

THE  WRIST- JOINT. 

Fluoroscopic  Examination. — In  examining  the  wrist-joint,  follow  the 
directions  given  for  the  hand ;  manipulate  the  part  gently,  so  as  not  to 
aggravate  the  injury.  This  examination  should  be  conducted  before 
splints  or  casts  are  applied.  Much  assistance  can  be  rendered  the 
surgeon  if  the  process  of  reduction  is  watched  through  a  fluoroscope. 

Skiagraphie  Examination. — The  wrist -joint  should  be  skiagraphed  in 
the  supine,  prone,  and  the  lateral  positions  both  before  and  after  reduc- 
tion and  also  before  removing  the  cast.  Place  both  the  hands  upon  the 
plate  for  comparison.  A  small  weight  is  placed  upon  the  hand,  or  the 
arm  is  strapped  to  a  board,  to  prevent  tremors.  In  the  lateral  position 
the  tremor  can  be  avoided  by  the  patient  grasping  a  book  or  other  small 
object. 

Lower  End  of  the  Rmlhix  <tn<l  Utna.—Au  epiphyseal  separation  at  the 
lower  end  of  the  radius  may  be  mistaken  for  a  Colics' s  fracture.  (Fig.  124. ) 


262  ELECTRO-THERAPEUTICS. 

It  must  he  home  in  mind  that  tbe  epipbysis  commences  to  ossify  about 
the  end  of  the  second  year  of  life,  and  unites  with  the  shaft  at  about 
the  nineteenth  or  twentieth.  Vertical  fracture  of  tbe  epiphysis  is  ran-. 

The  difficulty  in  detecting  this  fracture  is  due  to  a  wrong  position  of 
the  tube,  in  consequence  of  which  its  rays  not  falling  perpendicularly  do 
not  traverse  between  the  fragments  ;  or  the  shadows  of  the  fragments  may 
superimpose,  and  thus  obliterate  the  dark  line  on  the  negative. 

Though  dislocations  at  the  wrist-joint  were  regarded  by  the  older 
writers  as  of  infrequent  occurrence,  the  advancements  made  in  diagnosis 
and  tbe  discovery  of  the  X-rays  prove  them  to  be  of  much  greater  fre- 
quency than  was  formerly  supposed.  These  dislocations  may  be  back- 
ward, forward,  or  lateral,  and  may  occur  independently  of  fracture  of 
the  radius  or  ulna. 

THE  FOREARM. 

A  fluoroscopic  examination  of  the  forearm  is  conducted  in  the  same 
manner  as  for  the  wrist -joint. 

A  skiagraphic  examination  can  be  taken  while  the  arm  is  in  either 
the  supine,  prone,  or  lateral  position.  The  plate  should  be  8  x  10  inches 
(20x25  cm.),  the  time  of  exposure  from  5  to  10  seconds. 

Fractures  of  the  middle  third  of  the  radius  and  ulna  in  children  are 
discerned  with  difficulty  by  the  fluoroscope,  being  usually  the  so-called 
green-stick  fractures.  A  skiagraph  is  preferable.  (Fig.  125.) 

In  fractures  of  the  radius  and  ulna,  if  the  two  lines  of  injury  are 
near  each  other,  the  subsequent  callus  formation  may  bring  these 
bones  together,  thus  producing  a  synostosis,  which  will  interfere  writh 
rotation  of  the  arm.  The  X-rays  will  indicate  the  amount  of  callus 
thrown  out. 

In  Colles's  fracture  a  skiagraph  taken  in  the  antero-posterior  posi- 
tion may  not  show  the  fracture,  or  should  the  fracture  appear  the  degree 
of  displacement  of  the  lower  fragment  may  not  show  at  all.  This  will 
necessitate  a  skiagraph  taken  in  the  lateral  positions  ; — i.  e.,  the  ulnar  or 
radial  sides  being  in  contact  with  the  plate.  (Figs.  120,  121.) 

In  the  oblique  type  of  Colles's  fracture  the  line  of  dissolution  often 
includes  a  chipping  off  of  the  styloid  process  of  the  radius. 

Fracture  of  the  styloid  process  of  the  radius  may  be  found  inde- 
pendent of  (Figs.  122,  123),  or  in  connection  with,  Colles's  fracture. 
Often  the  anterior  border  of  the  radius  is  fractured,  producing  subluxa- 
tiou  of  the  wrist. 

Multiple  fracture,  especially  that  form  known  as  the  Y-fracture,  is 
more  common  than  is  usually  supposed. 

The  supine  or  prone  position  of  the  wrist  may  show  in  the  skiagram 
either  lateral  displacement,  transverse,  oblique,  or  Y-fracture,  and  fissure 
or  fracture  of  the  styloid  process  of  the  radius. 


FIG.  117.— Inward  dislocation  of  the  first  phalanx  of  the  thumb.   (Case of  Dr.  G.  E.  Shoemaker.) 


1 


Fio.  118.— The  normal  hand,  taken  with  high-vacuum  tube. 


FIG.  119.— Fracture  of  the  scaphoid,  1,  1. 


FIG.  120.  FIG.  121. 

COLLES'S  FRACTURE. 
(Antero-posteriorview.)  (Lateral  view.) 

Left  picture,  taken  in  the  prone  position,  shows,  at  F >•  and  F,  a  transverse  fracture  of  the 

radius  and  a  green-stick  fracture  of  the  ulna.    E »•  and  E >-  are  the  ununited  epiphyses.    The 

right-hand  picture  is  the  same,  taken  in  a  lateral  position.    (Case  of  Dr.  Franklin  Brady.) 


FIG.  122.— Fracture  of  styloid  process  of  the  FIG.  123.— The  same,  in  the  prone  position, 

ulna  (supine  position,  hand  slightly  abducted).          which  does  not  show  the  fracture  (arrow  5). 


FIG.  124. — TvprcAi,  COLLES'S  FRACTURE. — The  bones  appear  white,  as  seen  on  the  negative: 
1,  scaphoid  ;  2,  semilunar ;  3,  cuneiform  ;  4,  pisiform  ;  5,  unciform ;  6,  os  magnum  ;  7,  trapezoid ; 
8,  trapezium. 


THE  CLINICAL  APPLICATIONS.  263 

Occasionally  the  styloid  process  carries  with  it  when  fractured  a 
part  of  the  dorsal  border  of  the  radius  ;  this  is  known  as  Barton's  frac- 
ture. Colics' s  fracture  is  frequently  associated  with  fractures  of  the 
styloid  process  of  the  ulna  accompanied  by  rupture  of  the  triangular 
fibro-cartilage. 

THE  ELBOW-JOINT. 

F 1  noroscopic  Examination. — It  is  very  unsatisfactory  to  examine  the 
elbow  in  the  antero- posterior  position  with  the  ordinary  fluoroscope,  as 
the  curvature  of  the  part  prevents  a  close  approximation  of  the  screen. 
To  meet  this  difficulty  it  is  necessary  to  employ  a  small  tubular  fluoro- 
scope which  fits  snugly  the  anterior  surface  of  the  joint.  A  disadvan- 
tage of  this  fluoroscope  is  the  small  area  brought  into  view.  To  obviate 
this  the  author  has  devised  a  flexible  fluoroscope  which,  when  properly 
used,  will  bring  all  the  parts  into  view. 

The  lateral  position  is  by  far  the  most  convenient  one  in  which  to 
examine  injuries  of  the  elbow-joint  with  the  fluoroscope.  The  joint 
should  be  viewed  from  the  internal,  external,  and  lateral  positions. 

tikiagraphic  Examination  of  the  Elbow.— Skiagraph  the  elbow  either 
in  the  anterior,  posterior,  or  antero-posterior  position.  The  forearm 
should  be  well  extended  and  placed  in  the  supine  position.  The  sensi- 
tive plate  8x10  inches,  (20x25  cm.)  is  placed  under  the  olecrauon 
process  of  the  ulna,  with  the  tube  held  at  a  distance  of  from  12  to  16 
inches  (30  to  40  cm.)  above  the  joint. 

The  elbow-joint  is  best  shown  in  two  views,  the  antero-posterior  and 
the  lateral. 

To  skiagraph  the  elbow  in  the  postero-anterior  position,  place  the 
patient  in  the  ventral  recumbent  posture,  with  the  arm  extended  by  his 
side.  Place  a  small  plate  under  the  joint,  remembering  that  it  should  be 
as  near  the  bones  as  possible. 

A  sensitive  film  can  be  placed  in  the  flexure  of  the  elbow -joint  and 
the  tube  beneath  the  table ;  a  convex  block  of  wood,  also  conforming 
to  the  contour  of  the  flexure  of  the  joint,  will  hold  the  film  in  position. 

In  the  lateral  position  the  plate  should  be  placed  either  under  the 
internal  surface  of  the  elbow  with  the  tube  above  the  joint,  or  over  the 
external  surface  with  the  tube  beneath  the  table,  the  former  being  prefer- 
able. In  both  of  the  above  methods,  the  elbow  should  be  flexed  and 
brought  on  a  level  with  the  shoulder  of  that  side. 

To  properly  interpret  the  shadows,  a  normal  corresponding  joint  in 
the  same  individual  must  first  be  carefully  studied;  especially  is  this 
the  case  with  children.  In  the  antero-posterior  position,  we  notice  the 
shadow  of  the  olecranou  process  clearly  visible  and  superimposed  upon 
the  shadow  of  the  sigmoid  fossa.  Light  shadows  are  seen  between  the 
articulating  surfaces  of  the  huinerus  and  ulna. 


264  E LECTRO-TH  E 11 A I '  E  UTICS. 

A  skiagram  of  the  elbow  in  the  antero-posterior  position  always 
shows  a  light  horizontal  shadow  between  the  internal  condyle  of  the  hu- 
merus  and  the  coronoid  process  of  the  ulna,  which  has  often  deceived  the 
inexperienced  into  diagnosing  a  fracture  of  the  olecranou.  Fig.  120  shows 
the  lighter  portion  extending  inward  between  10  and  7,  toward  11.  This 
shadow  is  in  reality  that  of  the  olecranon  process  of  the  ulna,  and  is 
deceptive,  because  it  is  bounded  by  heavier  shadows,  which  are  cast  by 
the  humerus  and  olecranon  on  one  side,  and  by  the  coronoid  and  the 
olecranon  processes  on  the  other. 

Fractures  of  the  head  or  neck  of  the  radius  are  of  rare  occurrence. 
(Fig.  126.) 

Separation  of  the  epiphyses  is  extremely  rare.  (Fig.  127.)  It  is 
convenient  to  know  that  ossification  begins  about  the  sixth  year,  and 
union  with  the  diaphysis  occurs  about  the  sixteenth  or  seventeenth  year. 

Fractures  of  the  upper  third  of  ulna,  with  dislocation  of  the  head  of 
the  radius,  are  skiagraphed  by  lateral  exposure.  (Fig.  128.) 

In  longitudinal  fracture  of  the  upper  end  of  the  ulna,  the  lateral 
position  will  not  reveal  the  fracture,  but  it  must  be  skiagraphed  in  the 
antero-posterior  position. 

In  order  to  separate  the  fragments,  when  the  fracture  is  in  close 
proximity  to  the  insertion  of  the  brachialis  anticus,  the  arm  should  be 
well  extended  during  the  examination. 

Dislocation  of  the  Elbow-Joint. — For  dislocations  of  the  elbow-joint  a 
lateral  view  should  be  taken  with  fluoroscopic  and  skiagraphic  examina- 
tions. In  children,  this  dislocation  may  simulate  epiphyseal  separation. 
Supra-condyloid  fracture,  partial  fracture  of  the  internal  epicondyle,  and 
partial  detachment  of  the  external  coudyle  of  the  humerus,  are  well 
shown  in  Figs.  129,  130,  131,  and  132.  Detachment  of  the  supinator 
longus  muscle,  simulating  a  fracture  of  the  humerus  and  epiphysitis  of 
the  humeral  head,  at  first  thought  to  be  a  fracture,  are  depicted  in  Figs. 
133,  134,  and  135. 

THE  MIDDLE  THIRD  OF  THE  HUMERUS. 

Fluoroscopic  and  skiagraphic  examinations  readily  reveal,  from  all 
sides,  fractures  of  the  middle  third  of  the  humerus. 

THE  SHOULDER-JOINT  AND  ITS  VICINITY. 

On  account  of  the  immediate  swelling  of  the  part,  examination  is 
often  rendered  very  difficult. 

Fluoroscopic  Examination. — If  the  patient  is  a  child  or  a  thin  person, 
this  method  of  examination  will  !><>  satisfactory. 

Should  one  suspect  fracture  with  dislocation,  it  is  preferable  to 
take  a  skiagram,  as  it  requires  less  disturbance  of  the  parts.  The 
examination  is  made  in  the  antero-posterior  position. 


THE  CLINICAL  APPLICATIONS.  265 

Fractures  of  the  surgical  neck  of  the  humerus  are  quite  common 
(Fig.  136),  while  fractures  of  the  anatomical  neck  are  very  rare. 

In  skiagraphing  the  shoulder-joint,  in  order  to  avoid  erroneous  inter- 
pretations, the  operator  should  always  bear  in  mind  that  the  epiphysis 
and  diaphysis  do  not  unite  until  the  twentieth  year. 

Skiagraphic  Elimination. — The  patient  is  placed  in  the  dorsal  recum- 
bent posture,  the  head  being  supported  by  a  low  pillow,  and  the  uu- 
bandaged  arm  is  extended  to  an  angle  of  35°,  and  is*immobilized  by 
employing  a  sand-bag  or  small  weight. 

In  corpulent  individuals  the  head  of  the  humerus  may  be  too  distant 
from  the  sensitive  plate.  This  may  be  remedied  by  simply  tilting  the 
patient  to  that  side,  or  by  raising  the  uninjured  shoulder  on  a  pillow. 
The  rays  should  be  directed  over  the  lower  border  of  the  glenoid  cavity. 

In  viewing  from  the  anterior  position,  the  patient  may  lie  either  on 
his  abdomen  or  on  his  back.  When  the  patient  assumes  the  former 
position,  the  tube  is  placed  over  the  spiuous  process  of  the  scapula,  and 
the  plate  rests  on  the  table,  under  the  joint.  In  the  dorsal  recumbent 
position  the  tube  is  placed  under  the  table,  and  the  patient  may  rest 
either  in  the  dorsal  decubitus  or  semi-recumbent  position.  I  put  the 
plate  in  an  adjustable  plate-holder,  which  prevents  it  from  coming  in  con- 
tact with  the  patient.  The  rays  should  be  applied  only  during  the  period 
in  which  the  patient  holds  his  breath,  after  a  full  inspiration  or  expira- 
tion. These  intermittent  exposures  should  be  repeated  4  or  5  times. 
This  method  prevents  the  blurred  effects  which  one  sees  occasionally. 

Dislocations  or  Subhixatiotis  of  the  Shoulder. — In  these  classes  of  cases 
there  is  likelihood  of  wrong  interpretation  of  the  skiagraphed  part,  as 
different  positions  of  the  tube  and  arm  will  give  varying  relations  of  the 
humeral  head  to  the  glenoid  cavity.  In  order  to  guard  against  this  error, 
a,  large  plate  should  be  used  on  both  shoulders,  and  the  parts  skiagraphed 
simultaneously,  by  placing  the  tube  on  the  median  line,  and  maintaining 
both  shoulders  and  arms  in  precisely  the  same  position.  Instead  of 
using  one  large  plate,  we  may  employ  two  plates  placed  together. 

The  acromio-clavicular  space,  being  cartilaginous,  appears  as  though 
a  fracture  or  separation  existed.  Sometimes  this  light  area  is  exaggerated 
on  account  of  the  faulty  or  oblique  position  of  the  shoulder  or  part. 

The  oblique  ridge  separating  the  head  from  the  anatomical  neck 
often  shows  a  white  line  on  the  negative.  A  depression  where  the 
spinatus  muscle  is  attached  may  also  be  seen  on  the  plate.  Fig.  137 
shows  a  fracture  of  the  acromion  process. 

THE  CLAVICLE. 

Fractures  of  the  clavicle  occur  mostly  in  children,  yet  they  may 
happen  at  any  age.  (Fig.  138.)  Skiagraphic  examinations  are  best 
obtained  by  taking  either  anterior  or  posterior  views.  Dislocation  of 
the  scapular  end  and  other  varieties  can  be  readily  discerned. 


•_v,r,  ELECTEO-THERAPEUTICS. 

THE  SCAPULA. 

Fracture  of  the  scapula  is  best  skiagraphed  in  the  dorsal  recumbent 
posture.  The  coracoid  process  is  best  skiagraphed  with  the  patient  on 
his  abdomen  ;  the  better  method  is  to  place  the  tube  in  such  a  position 
that  the  rays  will  pass  through  the  axillary  space,  the  plate  being 
fastened  over  the  clavicle,  the  coracoid,  and  acromial  processes. 

Always  endeavor  to  throw  the  shadow  of  the  process  under  the  clear 
space  of  the  clavicle,  and  not  over  the  neck  of  scapula. 

FRACTURES  OF  THE  SKULL. 

Many  difficulties  are  met  in  skiagraphing  fractures  of  the  skull, 
owing  to  the  superimposition  of  the  shadows  of  the  bony  Avails  surround- 
ing the  part  under  examination,  and  the  difficulty  in  bringing  the  plate  in 
proper  apposition  to  the  curved  outline  of  the  skull  cap.  Fluoroscopic 
examinations  are  satisfactory  in  the  thin  skulls  of  young  children.  Skia- 
graphs can  be  taken  in  the  lateral,  the  fronto-occipital,  and  the  occipto. 
frontal  positions,  but  the  lateral  view  affords  greater  detail  of  structure 
and  offers  a  clearer  field. 

Fissured  fracture  of  the  base  defies  detection,  because  the  line  of 
fracture  is  inaccessible  in  any  position  in  which  the  tube  may  be  placed. 
Any  change  in  the  contour  of  the  inner  or  outer  tables  of  the  skull  or  the 
presence  of  the  formation  of  callus,  can  be  brought  out  by  placing  the 
tube  and  plate  in  exactly  the  right  position,  which  can  be  determined  only 
by  constant  practice. 

IV.   Fractures  and  Dislocations  of  the  Lower  Extremity. 
THE  FOOT. 

Fractures. — Fractures  of  the  phalanges  of  the  foot  are  of  the  com- 
minuted or  splintered  type. 

Fractures  of  the  metatarsal  bones,  which  were  formerly  thought  to  be 
extremely  rare,  have  been  shown  by  the  X-rays  to  be  of  common  occur- 
rence. (Figs.  139  and  140.)  The  so-called  "swelling"  of  the  feet  is 
often  due  to  fracture  of  one  or  more  metatarsal  bones.  The  first  and  fifth 
of  these  bones  are  most  frequently  broken,  the  resulting  fracture  being  of 
the  compound  type. 

Fractures  of  the  astragalus  and  os  calcis  are  not  infrequent,  the  force 
travelling  through  the  body  or  neck.  This  injury  is  often  associated  with 
a  separation  or  a  dislocation  of  one  or  the  other  fragment.  Fracture  of 
the  os  calcis  may  involve  the  body  of  the  bone  or  one  of  its  processes,  and 
is  frequently  comminuted.  Fractures  of  the  astragalus  and  os  calcis  can 
readily  be  seen  on  the  screen  if  there  is  sufficient  separation  of  the 
fragments.  The  lateral  view  is  always  preferable. 

Fractures  of  the  phalanges  and  metatarsal  bones  may  be  disclosed  by 
a  fluoroscopic  examination.  Skiagrams  of  these  fractures  may  be  made 


Fin.  125.— Green-stick  fracture  of  the  ulna,  B,  with  a  transverse  fracture  of  the  radius,  D. 
A  and  C  are  the  epiphyses. 


Fro.  1-26.— Fracture  of  the  neck  of  the  radius,  8. 


FIG.  127.— EPIPHYSEAL  SEPARATION  ASD  DISPLACEMENT  OF  THE  LOWER  Kxi>  OF  TIIE  Hrvri:r>. 
The  eondylesS,  4,  remain  at  their  normal  positions,  the  diaphysis  having  suffered  a  lateral 
inent.    The  dotted  line  indicates  the  normal  position  that  the  diaphysis  should  occupy. 


Fio.  128.— Fracture  of  the  ulna  and  displacement  of  the  head  of  the  radius,  8. 


FIG.  129.— Supracondyloid  fracture  of  the  humerus. 


FIG.  130.— Fracture  of  part  of  the  internal  epicondyle  after  forcible  reduction  for  dislocation. 


. 

Fio.  131.— Detachment  of  a  portion  of  the  external  condyle  of  the  humerus,  antero-posterior  view. 

Fio.  132.— The  same,  lateral  view.  3,  inner  condyle ;  4,  olecranon  fossa  ;  5,  external  condyle  ; 
6,  olecranon  process ;  7,  coronoid  process  of  the  ulna ;  8,  centre  of  ossification  of  the  head  of  the 
radius.  (Case  of  Dr.  Franklin  Brady.) 


FIG.  133.— DETACHMENT  OF  THE  SUPINATOR  Losers  MrscLE,  ISDICATED  BY  THE  ARROW.— The  injury 
was  thought  to  be  a  fracture  prior  to  X-ray  examination.     (Case  of  Dr.  H.  C.  Kellner.) 


FIG.  134.— EPIPHYSITJS  OF  THE  HUMERAL  HEAD. 


FIG.  135.— THE  CORRESPONDISG  NORMAL  SIDE. 


Epiphysitis  of  the  head  of  the  humerus,  diagnosed  as  a  fracture.  3,  internal  epicondyle ; 
4,  olecranon  fossa  ;  5,  external  epicondyle ;  6,  olecranon  process ;  7,  coronoid  process  of  the  ulna ; 
8,  head  of  the  radius ;  9,  tuberosity  of  the  radius ;  10-11,  trocblea ;  11,  centre  of  ossification  of  the 
capi  tell  urn. 


' 


Fio.  136.— Subluzation  of  the  shoulder-joint,  L  - 

surgical  neck. 


F >•  is  a  fracture  of  the 


FIG.  137.— Fracture  of  the  acromion  process, >•  F.    (Case  of  Dr.  C.  H.  Burr.) 


FIG.  138.— Fracture  of  the  acromial  end  of  the  clavicle.    (Case  of  Dr.  W.  L.  Rodman. ) 


FIG.  139.— Fractures  of  the  1st,  2d,  3d.  and  4th  metatarsal  bones  and  of  the  1st  phalanx 

of  the  great  toe. 


THE  CLINICAL  APPLICATIONS.  l't;7 

in  a  number  of  positions.  In  the  anterior-posterior  position  the  patient 
occupies  a  high  stool  with  a  back  rest,  which  affords  greater  comfort  and 
lessens  the  possibility  of  movement.  The  foot  should  be  placed  oil  a 
small  supporting  bench  which  may  serve  as  a  holder  for  the  sensitive 
plate  as  well. 

The  foot  is  extended  by  gradually  moving  the  bench  from  the  stool, 
the  patient  in  the  meantime  being  instructed  to  keep  the  sole  of  the  foot 
evenly  upon  its  top.  In  skiagraphing  a  "partial"  lateral  view  the 
rays  from  the  tube  should  fall  more  or  less  obliquely,  thus  preventing  a 
snperimposition  of  the  metatarsal  shadows. 

Skiagraphy  of  the  tarsal  bones  is  more  difficult.  The  astragalus  may 
be  successfully  skiagraphed  in  an  antero-posterior  view,  by  placing  the 
tube  anteriorly  at  the  upper  angle  of  the  foot  and  the  sensitive  plate 
posteriorly,  plantar  or  dorsal.  Put  both  feet  close  together  upon  two 
separate  8  x  10  inch  (20  x  25  cm.)  plates,  with  the  tube  in  the  centre.  The 
tarsal  articulation  can  be  best  skiagraphed  by  placing  the  plate  against 
the  dorsum  of  the  foot  and  allowing  the  rays  to  penetrate  through  the 
plantar  surface. 

Dislocations. — Phalangeal  dislocations  of  the  foot  closely  correspond 
to  those  of  the  hand,  but  are  of  much  less  frequent  occurrence. 

Dislocation  of  the  metatarsal  bones  at  the  tarso- metatarsal  articula- 
tion, usually  occurs  as  a  complete  displacement  involving  several  or  all  of 
the  metatarsal  bones  on  the  dorsuui  of  the  foot.  Plantar  dislocations  are 
very  rare. 

The  technic  in  dislocations  is  practically  the  same  as  has  been 
discussed  under  fractures. 

THE  ANKLE-JOINT  AXD  CONTIGUOUS  STRUCTURES. 

Fractures. — Fractures  of  the  ankle-joint  involve  the  tibia,  fibula,  and 
tarsal  bones,  either  alone  or  in  combination.  For  all  practical  purposes 
they  should  be  divided  into  two  groups,  dislocation-fracture  and  sprain- 
fracture. 

A  suprarnalleolar  fracture  of  the  tibia  and  fibula  is  best  skiagraphed 
autero-posteriorly.  Skiagrams  of  typical  Pott's  fracture  show  a  trans- 
verse or  oblique  line  of  injury  in  the  lower  third  of  the  fibula,  with  frac- 
ture of  the  malleolar  processes  of  the  tibia,  (Fig.  141.)  A  skiagram  is 
best  made  by  placing  the  patient  in  a  recumbent  or  semi-recumbent  posi- 
tion. The  sensitive  plate,  8x10  inches  (20x25  cm.),  should  be  placed 
directly  under  the  seat  of  the  injury,  as  low  as  the  os  calcis,  the  leg  being 
slightly  rotated  inward  to  prevent  superimposition  of  the  shadows  of  the 
tibia  and  fibula.  The  tube  should  be  about  20  inches  (50  cm.)  distant 
from  the  plate.  The  time  of  exposure  varies  between  10  and  20  seconds. 
"NVhen  the  fracture  is  longitudinal,  without  displacement,  the  antero-pos- 
terior  view  may  fail  to  reveal  the  presence  of  fracture;  in  such  a  case,  it 


268  ELECTRO-THERAPEUTICS. 

is  imperative  that  a  lateral  view  should  be  taken,  with  the  suspected 
side  next  to  the  plate.  A  fracture  box  should  be  employed  to  secure 
immobilization. 

Epiphyseal  separation  and  malleolar  and  supramalleolar  fractures 
must  not  be  confounded  with  Pott's  fracture. 

Dislocations  of  the  ankle  present  nothing  characteristic  and  there- 
fore require  no  special  technic.  They  should  be  examined  in  both 
positions. 

THE  LEG  (MIDDLE  THIRD).     (Figs.  142,  143.) 

Fractures. — When  making  antero- posterior  and  lateral  skiagrams  in 
this  region,  prevent  the  shadow  of  the  tibia  superimposing  upon  that  of 
the  fibula,  or  vice  versa. 

THE  KNEE-JOINT. 

Fractures. — Complete  transverse  fracture  of  the  tibia  in  its  upper 
third,  fracture  of  the  tuberosity,  and  traumatic  epiphyseal  separation  of 
the  upper  end  of  the  tibia,  are  readily  discerned  by  the  X-rays. 

The  knee-joint  should  be  examined  from  two  views,  either  the  antero- 
posterior  or  the  lateral.  A  fluoroscopic  examination  of  the  knee-joint  is 
rather  unsatisfactory  except  in  ankylosis.  Gliding  movements  of  the 
various  ligaments  and  patella  may  be  studied,  and  severed  ligaments  can 
often  be  detected.  In  osseous  ankylosis  the  articular  plane  of  the  knee  is 
obliterated,  while  in  the  fibrous  form  there  is  usually  no  such  obliteration. 

In  making  antero- posterior  skiagrams,  have  the  patient  on  his 
back,  with  the  head  and  chest  elevated,  the  extremity  of  the  foot  fixed 
resting  upon  an  extension  of  the  operating  table,  or  tied  to  fracture  box. 
A  sensitive  plate  8  x  10  inches  (20  x  25  cm.)  is  placed  against  the  posterior 
aspect  of  the  knee-joint,  with  the  tube  directly  over  the  patella.  The 
shadow  of  the  patella  is  usually  very  faintly  superimposed  upon  that  pro- 
duced by  the  lower  end  of  the  femur.  The  patellar  shadow  is  increased 
in  density  if  the  plate  is  placed  in  front  of  the  patella  and  close  to  it,  the 
rays  being  allowed  to  penetrate  from  behind.  In  making  lateral  skia- 
grams the  patient  should  lie  upon  the  injured  side  with  the  fractured 
joint  slightly  flexed,  the  other  leg  should  be  extended  or  fully  flexed  so  as 
not  to  interfere  with  passage  of  the  rays.  Detachment  of  the  tubercle  of 
the  tibia  is  shown  in  Fig.  145. 

Fractures  of  the  Patella  (Fig.  144). — In  transverse  fracture  of  the  pa- 
tella, the  lateral  fluoroscopic  view  shows  the  separation  of  the  fragments. 
Stellate  and  fissured  fractures  can  only  be  shown  by  a  skiagraph  taken  in 
the  postero-anterior  position.  The  patient  should  lie  face  down,  with  the 
tube  behind  the  joint  and  the  plate  under  the  patella.  The  sesamoid 
bones  give  distinct  shadows  and  float  ing  or  loose  bodies  are  often  detected. 
Detached  cartilages  are  very  difficult  (and  often  impossible)  to  skiagraph. 


THE  CLINICAL  APPLICATIONS.  269 

THE  FEMUR  (MIDDLE  AND  LOWER  THIRDS). 

Fracture*. — Fractures  of  the  shaft  of  the  femur  are  common.  In 
children  the  injury  is  usually  transverse  with  little  or  no  displacement, 
while  in  adults  it  is  usually  oblique  with  much  displacement.  In  making 
skiagrams  of  the  shaft,  two  plates,  in  exactly  opposite  directions,  should 
be  taken.  Fractures  of  the  lower  third  of  the  femur  are  easily  diagnosed 
by  the  X-rays. 

THE  HIP-JOINT. 

Fractures. — Fractures  of  the  upper  end  of  the  femur  are  divided  as 
follows  :  (1)  intra-capsular,  (2)  epiphyseal  separation,  (3)  extra-capsular, 
(4)  fracture  of  the  trochanters,  (5)  isolated  fracture  of  the  trochanter 
major,  and  (6)  fracture  of  the  upper  portion  of  the  shaft  immediately 
below  the  trochanters. 

Fluoroscopic  examination  of  the  hip-joint  in  children  is  usually 
satisfactory,  but  the  thickness  of  the  tissues  makes  it  unsuited  for  adults. 
At  best,  skiagraphy  of  the  adult  hip-joint  is  troublesome,  especially  if  the 
subject  is  very  corpulent  and  the  part  painful. 

The  technic  is  as  follows :  Have  the  patient  fully  extend  the 
leg  of  the  injured  side.  If  this  is  impossible,  place  a  pillow  under  the 
partially  flexed  knee.  Place  two  superimposed  plates,  10  x  12  inches 
(25  x  30  cm.)  or  11  x  14  inches  (28  x  35  cm.),  under  the  hip,  which 
should  extend  from  the  iliac  crest  and  project  two  inches  from  the  outer 
aspect  of  the  leg.  The  tube  should  be  placed  directly  over  the  head 
of  the  femur,  and  from  20  to  25  inches  (50-63  cm.)  from  the  plate.  If 
the  foot  is  inverted  or  everted  from  the  injury,  do  not  correct  it.  Guard 
against  tremors  by  the  use  of  a  pillow,  sand-bags,  bandages,  or 
suspended  weights. 

It  is  often  valuable  to  take  both  hip-joints  at  the  same  time  for  com- 
parison. For  this  employ  either  a  large  plate  that  will  include  the 
shadows  of  both  hips  or  two  smaller  plates  touching  side  by  side.  Adjust 
the  tube  to  the  median  line  at  a  distance  of  more  than  20  or  25  inches 
(50-63  cm.),  the  anode  pointing  to  the  pubic  symphysis,  remembering 
that  this  position  will  require  a  longer  exposure.  It  must  never  be  for- 
gotten that  certain  positions  of  the  foot  will  cause  the  neck  of  the  femur 
to  assume  varying  angles,  shapes,  and  lengths  to  the  acetabular  cavity,  and 
that  the  shape,  distance,  and  position  of  the  lesser  trochanter  will  change 
its  relation  to  the  descending  ramns  of  the  pubis.  To  convince  others 
of  the  correct  interpretation  of  the  negative,  employ  as  a  confirmatory 
measure  a  simultaneous  skiagraph  of  both  hip-joints,  previously  securely 
binding  the  feet  and  ankles  in  the  vertical  position,  thus  placing  the 
necks  of  the  femora  in  identical  positions,  or  take  another  without  tying 
the  feet,  and  let  the  feet  occupy  their  actual  positions  in  order  to  show 
the  difference.  As  very  fine  detail  work — i.  e.,  the  structural  texture  of 


270  ELECTRO-THERAPEUTICS. 

the  femur — must  especially  be  brought  out,  it  is  apparent  that,  if  this 
sharpness  of  definition  is  lacking,  an  impacted  or  fissured  fracture  might 
easily  escape  detection. 

In  doubtful  and  obscure  cases,  advantage  is  gained  by  making  another 
skiagram  in  the  ventral  position  ;  because  of  the  thickness  of  this  region, 
the  time  of  exposure  is  lessened  by  using  the  intensifying  screen,  which 
sacrifices,  however,  the  fine  details.  I  therefore  do  not  recommend  it. 

A ntero- posterior  fractures  of  the  acetabuluin  can  readily  be  skia- 
graphed,  but  stellate  fracture  is  extremely  difficult  to  determine.  Skia- 
grams of  impacted  fractures  of  the  neck  of  the  femur  do  not  present  the 
usual  light  lines.  The  fracture  can,  however,  be  diagnosed  by  the  short- 
ening, and  the  slight  irregularity  in  the  size,  shape,  and  angle  of  the  neck 
of  the  femur. 

The  osseous  ridge  running  between  (intertrochanteric  ridge)  the  tro- 
chanters  posteriorly,  usually  gives  a  light  line  on  the  negative,  which  must 
not  be  mistaken  for  fracture.  In  the  fracture  at  the  base  of  the  neck, 
the  angle  diminishes  from  the  normal  to  90°  or  less.  An  incomplete, 
intertrochanteric  fracture  is  well  shown  in  Fig.  146. 

Chemical  intensification  of  a  negative  defines  the  osseous  tissue  more 
clearly,  but  as  the  detail  of  the  soft  structure  is  thereby  diminished,  a 
second  exposure  is  preferable,  if  possible. 

A  satisfactory  negative  should  clearly  differentiate  the  head  and 
neck  of  the  femur  and  the  hip  bones.  If  not  sufficiently  dense,  the 
lines  and  shadows  indicative  of  fracture  will  not  be  visible.  The 
tendency  in  making  these  negatives  is  to  over  expose,  but  better  results 
are  obtained  by  using  a  tube  of  high  penetrability,  with  an  electrolytic 
interrupter. 

Dislocations. — Congenital  dislocation  of  the  hip  in  children  (Figs.  147 
and  148)  can  be  well  demonstrated  by  skiagrams,  showing  the  presence  or 
absence  of  the  ring  of  the  acetabular  cavity,  the  depth  of  the  acetabulum^ 
the  position,  shape,  and  situation  of  the  head  of  the  femur.  I  have  made 
studies  of  a  series  of  cases,  before  reduction,  after  reduction  through  the 
cast,  and  after  removal  of  the  cast,  in  the  service  of  Professor  Adolf 
Lorenz  during  his  recent  visit  to  this  country,  and  they  proved  to  be  very 
suitable  and  interesting  from  a  stereo-skiagraph ic  stand-point. 

Pathological  dislocations  (Figs.  149  and  150)  the  result  of  tuber- 
culosis, osteo-arthritis,  Charcot's  disease,  etc.,  are  easily  skiagraphed  in 
the  manner  outlined  under  fractures.  In  pathological  dislocations  11m 
head  and  neck  of  the  bone  are  absent,  as  in  cases  of  epiphysitis. 

Tin   ()s  INNOMINATA,  SACRUM,  AND  COCCYX. 

l-'mctures. — The  clinical  diagnosis  of  fracture  of  the  pelvis  can  only 
be  made  when  the  separation  of  the  bones  is  marked  or  when  displace- 
ment is  considerable.  When  only  slight  separation  exists,  the  X-rays 


FIG.  110.— FRACTURE  OF  THE  MIDDLE  OF  THE  FOURTH  METATARSAL  BONE.— I,  II,  III  are  the  meta- 
tarsal  bones;  A,  1st  internal  cuneiform;  B,  2d  middle  cuneiform;  C,  3d  external  cuneiform;  D, 
cuboid  bone ;  E,  scaphoid ;  F,  astragalus ;  G,  anterior  process  of  the  os  calcis ;  1,  2,  sesamoid  bones. 


FIG.  141.— POTT'S  FRACTURE.— F *-,  F »•,  fractures  of  both  malleoli ;  I) >•  shows  the  in- 
ward dislocation  of  the  tibia.  The  internal  malleolus,  at  2,  should  be  in  the  dotted  area,  having 
become  detached  and  left  in  the  position  marked  2  (white). 


FIG.  142.— FRACTURE  op  THE  TIBIA  AND 
FIBULA,  TAKEN  AT  AN  ANGLE  BETWEEN  THE 
ANTERO-POSTERIOR  AND  LATERAL  POSI- 
TIONS.—This  skiagram  fails  to  show  any 
overlapping  of  the  fragments  of  the  fibula, 
but  exhibits  the  presence  of  callus. 


FIG.  143.— Lateral  view  of  the  same,  reveal- 
ing a  pronounced  overlapping  of  the  fragments. 
(Case  of  Dr.  W.  L.  Rodman.) 


FIG.  144.— Fracture  of  the  anterior  portion  of  the  patella. 


Fio.  145.— Detachment  of  the  tubercle  of  the  tibia,  result  of  a  kick  in  a  game  of  foot-ball, 
(Case  of  Dr.  Carlos  M.  Desvernine.) 


FIG.  140.— Incomplete  intertrochanteric  fracture.    (Case  of  Dr.  W.  L.  Rodman.) 


FlG.    147.— COXGEMTAL    DISLOCATION    OF  THE    HEAD    OP    THE    LEFT    FEMUR.— 1,   ICSSCf   tfOChanter ;     2, 

greater  trochanter ;  3,  heart  ;  4,  neck ;  5,  acetabulum.     (Case  of  Dr.  H.  Augustus  Wilson.) 


FIG.  148.— CONGENITAL  DISLOCATION  OF  BOTH  HIPS.— This  skiagraph  was  taken  by  me  after 
reduction  by  Dr.  Adolf  Lorenz  of  Vienna. 


FIG.  149.— PATHOLOGICAL  DISLOCATION  OF  LEFT  HIP  IN  A  CHILD  OF  Six  YEARS.— When  one  year 
old  an  abscess  developed,  which  was  incised  and  drained,  and  extension  applied.  Five  years  later  the 
skiagraph,  as  shown  above,  revealed  absorption  of  the  femoral  neck.  On  the  normal  side,  N  indicates 
the  neck ;  this  is  wanting  on  the  affected  side  (X  )•  1,  lesser  trochanter ;  2,  greater  trochanter ;  3,  head 

of  the  femur;  X,  neck  of  the  femur;  4 >-,  epiphyseal  line;    5,  acetabulum  ;  7,  iliac  fossa  ;  8,  epiph- 

ysis  between  the  ilium  and  ischium ;  9,  pubic  bone;  10,  obturator  foramen;  11,  ischium;  12,  pubic 
arch;  14,  ilio-pectineal  line;  16 >-  16,  sacro-iliae  synchondrosis ;  17,  crest  of  the  ilium;  18,  trans- 
verse process  of  the  5th  lumbar  vertebra ;  19,  fecal  matter  surrounded  by  light  area  (gas)  ;  C,  coccyx. 
(Case  of  Dr.  James  K.  Young.) 


Fio.  IJSO.— A  CASE  OF  PROBABLE  INFANTILE  PALSY.— The  patient's  left  femur  (right  side  in  the 
photograph)  shows  an  absence  of  the  neck,  and  also  a  transparent  area  at  the  dotted  portion  indicated 
at  X.  (Case  of  Dr.  James  K.  Young. ) 


THE  CLINICAL  APPLICATIONS.  271 

are  of  great  diagnostic  aid,  as  the  contour  of  these  bones  is  very  irregular 
and  the  rays  must  traverse  great  density  of  structure.  Fractures  of  the 
pelvic  bones  are  divided  into  those  in  which  the  individual  parts  are 
fractured  and  those  in  which  the  pelvic  rim  is  broken. 

In  skiagraphing  the  pelvis  the  patient  must  assume  the  ventral  and 
dorsal  decubitus  positions.  In  a  skiagraph  of  the  sacro-coccygeal  region 
the  tube  should  be  placed  over  the  umbilicus  so  that  the  shadow  of  the 
pubic  symphysis  will  not  overlap  the  shadow  of  the  sacrum  or  coccyx. 
The  rectum  should  be  emptied  by  an  enema  prior  to  the  examination. 

The  ilium,  ischium,  and  the  pubes  can  be  skiagraphed  in  the  above 
manner,  with  slight  modifications  in  the  relation  of  the  tube,  the  part, 
and  the  plate. 

THE  SPINAL  COLUMN. 

For  the  sake  of  conveniently  studying  the  spinal  column,  it  is  divided 
into  the  ccrrical,  dorsal,  and  lumbar  regions. 

The  cervical  region  is  best  skiagraphed  in  lateral  view.  Complete 
fracture  of  the  cervical  vertebne  can  easily  be  shown  in  skiagrams,  but 
incomplete  fracture  is  detected  with  great  difficulty.  In  my  experience 
I  have  found  the  fifth  and  sixth  cervical  vertebne  are  most  frequently 
fractured.  To  demonstrate  a  fracture  or  dislocation,  skiagrams  should  be 
taken  in  the  lateral  and  the  autero-posterior  position.  Recently  I  had 
two  cases  of  old  fracture-dislocations  of  the  fifth  cervical  vertebra,  and 
the  patients  are  still  alive.  I  have  had  four  cases  of  fracture  of  the 
cervical  vertebrae. 

Skiagrams  of  the  dorsal  region  are  somewhat  indistinct,  due  to  the 
super-imposition  of  shadows  cast  by  the  liver,  heart,  sternum,  and  ribs. 
I  have  had  four  fractures  of  the  second  and  eleventh  dorsal  vertebrae. 
The  best  definition  is  obtained  from  the  young  and  those  of  slender  build. 
In  thin  persons  autero-posterior  dislocations  may  be  shown  by  taking  the 
skiagram  in  the  lateral  view.  Of  course  distortion  will  be  exaggerated 
on  account  of  the  distance  between  the  plate  and  the  vertebra. 

Experience  proves  that  the  obstacles  encountered  in  making  skiagrams 
of  the  vertebral  column  are  numerous.  Thus,  the  peculiar  anatomical  ar- 
rangement in  this  locality,  the  projecting  and  irregular  processes  from  each 
vertebra,  and  the  impossibility  of  obtaining  the  desired  relations  between 
the  tube,  the  part,  and  the  plate,  make  this  procedure  a  most  difficult  one. 
The  dorsal  decubitus  should  be  selected  for  examining  all  regions  of 
the  spine ;  but  the  tube  should  be  placed  at  varying  positions,  and  in 
this  way  the  shadow  of  the  sternum  will  be  lessened  in  the  dorsal  region. 
This  technic  answers  for  the  dorsal  vertebrae,  but  the  upper  six  cervical 
should  be  taken  in  the  lateral  view.  Only  one  region  of  the  spine 
can  be  skiagraphed  at  a  time.  In  order  to  obtain  the  intra-articular 
spaces  clear  and  distinct,  it  must  not  be  forgotten  that  the  alimentary 


272  ELECTRO-THERAPEUTICS. 

canal  should  be  well  cleansed  previously.  The  negative  must  be  suffi- 
ciently dense  to  bring  out  strongly  and  sharply  the  shadow  of  each  verte- 
bra with  its  processes.  If  this  cannot  be  obtained,  resort  must  be  made 
to  chemical  intensification. 

The  technic  employed  for  the  lumbar  region  is  in  every  way  identical 
with  the  techuic  employed  in  renal  skiagraphy  (vide). 

THE  RIBS  AND  STERNUM. 

Fractures  of  the  sternum  are  best  examined  by  skiagraphing  in  the 
ventral  position.  The  ribs  can  be  examined  by  the  fluoroscope  in  differ- 
ent directions.  The  dorsal  and  ventral  views  will  reveal  the  fractures 
and  even  slight  fissures,  but  difficulty  is  encountered  at  the  angles  of  the 
ribs,  because  of  the  difficulty  in  approximating  the  plate,  and  the  neces- 
sity of  the  rays  traversing  diagonally  the  thickness  of  the  body,  and 
because  of  the  respiratory  movements. 

The  negative  clearly  reveals  the  presence  of  displacement.  A  slight 
fissured  fracture  may  often  escape  detection.  Care  should  be  taken  not  to 
confuse  the  costo-sternal  and  costo-vertebral  articulations  with  fractures. 
It  must  not  be  forgotten,  in  this  connection,  that  the  cartilages  are  trans- 
parent to  the  rays.  Fracture  of  the  ends  of  the  floating  ribs  may  be  de- 
tected. The  exposure  must  be  short,  and  made  preferably  at  the  end  of 
a  prolonged  inspiration,  the  patient  holding  his  breath  for  five  or  ten 
seconds.  Zinc-oxide  adhesive  plaster,  if  uniformly  applied  over  the  en- 
tire chest,  immobilizes  the  part  and  aids  the  skiagrapher,  but  a  few  strips 
applied  for  this  purpose  may  confuse  the  picture  on  the  negative  by 
casting  shadows,  in  conjunction  with  those  of  the  ribs. 

Do  not  mistake  the  various  grooves  or  prominences  in  the  ribs  for  a 
fracture. 

V.  Diseases  of  the  Osseous  System. 

As  the  osseous  system  is  largely  composed  of  mineral  matter  (cal- 
cium phosphate),  the  X-rays  in  their  passage  must  suffer  a  marked 
absorption  and  their  progress  meet  with  great  obstruction,  causing 
decreased  oxidation  on  the  plate,  and  offering  white  shadows  on  the 
negative,  thus  greatly  facilitating  its  study.  Some  think  that  the  rays 
throw  merely  a  shadow  or  silhouette  of  the  bone  on  the  plate,  but  the 
fallacy  of  this  view  is  apparent.  In  studying  the  photograph  of  the 
humerus,  for  example,  we  see  the  superimposition  of  various  strata  of 
different  densities ;  the  compact  portion  appears  denser  than  the  medul- 
lary, because  the  rays  in  the  former  must  traverse  more  osseous  structure. 
In  the  medullary  portion  the  negative  gives  a  darker  appearance,  because 
the  rays  are  only  compelled  to  pass  through  two  layers  of  bone,  the 
medullary  canal  intervening.  Ridges  appear  whiter,  and  fossae  darker, 
than  the  medullary  portion,  due  to  increased  density ;  foranrin*  show 


THE  CLINICAL  APPLICATIONS.  L'7.5 

as  dark  spots,  while  bony  canals  offer  dark  lines  on  the  negative.  Articu- 
lar cartilages  being  transparent  to  the  rays,  and  likewise  the  epiphyses, 
the  shadows  cast  will  be  dark. 

A.  PATHOLOGICAL  CONDITIONS. 

Any  pathological  condition  either  in  the  organic  or  inorganic  con- 
stituents will  offer  a  corresponding  change  in  the  shadow  thrown ;  the 
diseased  portion  of  bone  will  cast  a  shadow  lighter  or  darker  than  the 
surrounding  healthy  osseous  tissue,  and  likewise  of  the  same  bone  of  the 
opposite  side.  In  skiagraphing  osseous  tissue,  care  should  be  taken  to 
ascertain  the  presence  of  diseased  conditions  of  surrounding  soft  parts, 
such  as  an  effusion,  cyst,  tumor,  etc.,  as  their  presence  might  produce  a 
dense  shadow  that  could  be  interpreted  as  belonging  to  the  bone.  To 
corroborate  the  diagnosis,  a  skiagram  of  the  corresponding  part  should 
be  taken,  with  exactly  the  same  technic,  as  difference  in  the  position  of 
the  plate,  the  tube,  and  the  part  might  cause  a  difference  in  the  definition, 
shape,  and  size  of  the  shadow  produced.  When  possible,  expose  both 
parts  simultaneously. 

Arifff  ami  ('/ironic  Periostitis  and  Osteomyelitis. — Periostitis  is  charac- 
terized by  the  presence  of  a  fusiform  thickening  of  the  periosteum. 
This  must  not  be  mistaken  for  bony  irregularities. 

Osteitis  (osteo- myelitis)  is  marked  by  an  increase  in  shadow  density. 
(Figs.  151,  152.)  Eight  or  ten  days  after  the  injury  suppuration  occurs, 
and  about  the  twelfth  day  disintegration  of  bone  takes  place,  resulting 
in  the  production  of  a  lighter  shadow.  Later,  the  skiagraph  of  a 
sequestrum  will  be  revealed. 

Tuberculosis  of  Bone. — This  affection  is  characterized  by  numerous 
white  irregular  spots  which  have  a  natural  tendency  to  coalesce.  The 
shadow  cast  will  be  lighter  than  that  of  the  normal  bone,  because  the 
rays  traverse  less  density,  due  to  caseatiou  and  fibrous  tissue  formation. 
(Fig.  153.) 

Si/philix  of  Bone. — In  syphilis  of  the  bone,  two  conditions  are  en- 
countered,— the  occurrence  of  rarefaction  or  an  absorption  of  the  com- 
pact bony  structure,  and  a  sclerosis,  with  an  increase  in  density  of  the 
bone  affected.  The  infected  gummatous  portions  of  the  bone  cast  a 
lighter  shadow  than  does  the  normal  bone.  When  eburnation  occurs  the 
shadow  cast  will  be  darker,  but  the  density  of  the  shadow  will  not  be 
uniform,  an  irregular  thickening  encroaching  upon  the  medullary  canal 
being  evidenced.  In  the  adult  this  condition  is  differentiated  with 
difficulty  from  the  thickening  resulting  from  a  chronic  osteitis  and 
periostitis.  (Fig.  154.) 

Hi/pert  rophic  <]<  forming  osteitis  (Paget's  disease)  presents  a  hyper- 
trophy of  the  compact  tissue,  manifesting  a  very  dense  shadow. 

Leprosy. — Among  the  various  bone  lesions,  transparency  of  the 
is 


L>;  i  ELECTBO-TH  BRAPEUTIG8. 

digital  phalanges  is  most  frequent.  This  transparency  is  very  pro- 
nounced in  the  distal  phalanges,  though  it  may  be  equally  so  in  the 
others. 

AcromegaJy. — This  affection  may  be  more  thoroughly  understood  by 
a  careful  investigation  into  the  bony  peculiarities  of  the  skull.  A  great 
prominence  of  the  external  occipital  protuberance,  an  irregular  thick- 
ening of  the  cranial  parietes,  the  over-development  of  the  frontal  sinuses 
and  mental  eminence,  as  well  as  the  marked  hypertrophy  of  the  sella 
turcica,  make  this  means  of  diagnosis  of  incalculable  benefit.  The 
shadows  of  the  phalanges  show  the  epiphyses  to  undergo  an  enormous 
hypertrophy  and  deformity,  and  to  offer  no  obstruction  to  the  rays. 

Rickets. — In  this  disease  the  bone  appears  shorter  than  normal,  the 
diaphysis  slender,  the  epiphyses  enlarged,  and  the  line  of  calcification 
presents  an  irregular  appearance.  The  delay  in  the  process  of  ossification 
can  be  accurately  determined. 

Cretinism. — In  this  affection  there  is  supposed  to  be  a  premature 
union  of  theepiphysis  and  the  diaphysis,  resulting  in  an  arrested  growth 
of  the  bone. 

Langhans  and  von  Wyss1  found  that  there  is  no  hint  of  premature  os- 
sification in  cretins  and  cretinoids,  but  a  late  development  of  the  centres  of 
ossification  occurs,  and  consequently  at  or  after  the  age  of  development. 
the  epiphyses  show  a  delayed  union  ;  this  delay  in  the  process  of  ossifica- 
tion, as  compared  with  the  normal  individual,  is  of  a  few  years  only.  The 
bones  of  the  hand  are  the  last  to  ossify.  Hoffineister,  in  treating  a  cretin, 
observed  skiagraphically  that  when  the  child  was  treated  with  thyroid 
extract,  the  bones  under  examination  grew  4  cm.  in  four  mouths,  equiv- 
alent to  12cm.  in  a  year,  in  comparison  with  the  normal  growth  of 
6  cm.  annually. 

Osteomalacia. — In  osteomalacia  the  shadows  of  the  bones  will  be 
transparent,  and  as  the  disease  progresses  there  will  be  a  complete  ab- 
sence of  these  shadows. 

Necrosis  and  caries  are  characterized  by  transparent  shadows,  and  irreg- 
ularity in  the  contour  and  texture  of  the  bone.  (Fig.  155.)  Far  advanced 
cases  will  not  cast  a  shadow.  Skiagraphy  of  the  sequestra  is  of  marked 
service  to  the  surgeon,  informing  him  of  their  location,  number,  and  re- 
lations to  the  bone  itself  and  whether  they  are  still  adherent  or  exfoliated. 
Avoid  the  superimposition  of  their  shadows  with  those  of  the  bones. 

B.  TTMMKS  CF  BONES. 

Skiagraphy  enables  us  to  determine  if  a  neoplasm  is  connected  with 
the  compact  or  cancellons  portion  of  the  bone,  or  if  it  is  connected  with 
the  bone  at  all.  Thus,  the  growth  might  be  a  cyst  or  a  myoma  that 
closely  simulates  an  osteoma,  an  osteo-sarcoma,  etc. 

1  Fortechritte  a.  d.  Geb.  d.  Rontgenstr.,   I1.,  iii..  lsw-1900. 


FIG.  151.— Chronic  osteitis  with  eburnation,  as  indicated  by  the  arrows.    (Case  of  Dr.  M.  P.  Dickeson.) 


FIG.  1V2.— OSTEITIS  OF  THE  INDEX  FINGER  —  F.B.,  foreign  body  which  produced  the  condition  ; 
A  •+ was  the  point  of  entrance  of  the  foreign  body.    (Case  of  Dr.  Prendergast. ) 


FIG.  153.— TUBERCULOUS  OSTEITIS.— The  dotted  area  on  the  fourth  metacarpal  bone  shows  tuber- 
culous invasion  of  the  bone. 


FIG.  154.— Syphilitic  osteitis  of  the  radius. 


FIG.  155. — NECKOSIS  OF  THE  Os  CALCIS. — Right-hand  picture  shows  part  of  the  foot  of  a  patient 
who  complained  of  intense  pain  in  the  heel,  supposedly  due  to  an  ill-fitting  shoe ;  but  the  X-rays 
revealed  a  necrosis  of  the  os  calcis,  with  partial  absorption,  indicated  by  1.  The  left-hand  picture 

shows  the  normal  heel.    4  >-,  centre  of  ossification  of  the  epiphysis  of  the  tuberosity  of  the  cal- 

caneum  ;  A,  astragalus  ;  3  O.C.,  os  calcis  :  5,  fat  (dark  on  the  negative) ;  6,  tendo  Achillis  ;  7,  muscles ; 
s,  sinus  of  the  tarsus  ;  P,  plantar  arch  ;  C,  cuboid  ;  S,  scaphoid ;  V,  fifth  metatarsal.  (Patient  under 
care  of  Prof.  II.  A.  Wilson,  service  of  Philadelphia  Hospital.) 


FIG.  156.— Supernumerary  thumb.    ( Case  of  Dr.  George  M.  Boyd.) 


<          : 


.-- 


FIG.  157.— Congenital  absence  of  the  ulna  and  two  fingers.    (Case  of  Dr.  W.  Frank  Hnehnlen.) 


FIG.  158.— Congenital  multiple  exostoses.    (Cnse  of  Dr.  J.  P.  Mann.) 


THE  CLINICAL  APPLICATIONS.  L'", 

Osteo-sarcoma,  like  all  osseous  growths,  may  be  of  the  periostea!  or 
medullary  variety. 

In  periosteal  sarcoma,  the  growth  may  be  observed  to  start  laterally, 
but  later  to  completely  encircle  the  bone. 

In  the  early  stage  the  medullary  form  may  be  easily  confused  with 
syphilitic  osteitis  ;  in  the  latter  the  tendency  is  to  be  formation  of  clear 
spots,  that  later  become  multiple,  while  osteo-sarcoma  begins  with  a 
single  clear  spot,  becoming  gradually  enlarged  ;  it  is  never  multiple. 

Metastatic  carcinoma  has  been  shown  by  Benedict1  to  affect  osseous  as 
well  as  the  softer  tissues.  A  patient  under  his  care  suffered  from  cancer 
of  the  kidney,  and  later  had  it  removed.  Four  years  subsequently, 
intense  pain  was  diagnosed  as  sciatica,  but  the  X-rays  revealed  a  meta- 
static  carcinoma  of  the  last  lumbar  vertebra,  which  was  later  confirmed 
at  post-mortem.  Bone  cysts  can  also  be  detected. 

C.   DEFORMITIES  OF  BONES. 

Among  the  more  common  deformities  of  congenital  origin  are  super- 
numerary fingers,  or  the  absence  of  one  or  all  of  the  digits.  (Figs.  156, 
157. )  There  is  usually  either  a  second  little  finger  (the  most  frequent) 
or  a  second  but  smaller  thumb.  We  determine  if  the  additional  digit  is 
simply  tagged  on  by  the  skin,  or  if  a  distinct  and  completely  developed 
articulation  exists.  In  cases  of  supposed  giant  finger,  the  X-rays  will 
indicate  whether  the  bone  or  the  surrounding  tissue  has  undergone 
hypertrophy.  In  cases  of  syndactylisin  the  skiagrapher  can  often  deter- 
mine whether  bone  itself  partakes  in  the  union.  Hammer-fingers  are  of 
interest  in  that  the  joint  itself  is  not  diseased,  there  being  only  a  con- 
traction of  the  ligaments  and  tendons,  as  may  be  demonstrated  by  the 
fluorescent  screen. 

Exostoses  show  the  normal  compact  and  cancellous  structures.  (Fig. 
l.")S.  j  There  is  an  overgrowth  of  the  normal  bone,  the  epiphyseal  line 
presents  a  darker  color,  and  from  its  margins  spring  peculiar,  hook-like 
o-seous  projections. 

These  changes  produce  an  alteration  in  the  curvature  of  the  bone, 
with  atrophy  of  the  epiphysis  and  arrest  of  the  development  of  the  dia- 
pliysis.  Frequently  a  union  of  the  bones  (synostosis)  occurs,  but  the 
growth  is  usually  partially  inhibited  iu  one  of  them,  resulting  in  a  pecu- 
liar twisting,  readily  diagnosed  and  differentiated  from  rhachitis  and 
other  bone  diseases. 

Deformities  of  the  pelvis  and  pelviinetry  will  be  treated  of  in  the 
article  on  Obstetrics. 

Two  interesting  cases,  studied  by  Dr.  Charles  W.  Burr,2  of  congenital 
deformities  were  presumably  due  to  intra-uterine  disease  of  the  spinal 

1  Wiener  klin.  Wochenschrift,  June,  1899. 

2  Journal  of  the  American  Medical  Association,  June  11,  1904. 


276  ELBCTBO-THEBA  PKl'TICS. 

cord.  (Fig.  l.">9. »  The  first  cast-  was  a  male,  fifty-five  years  of  age,  four 
feet  tall ;  head  and  skin  normal,  no  anaesthesia,  sensation  preserved  all 
over  the  body  ;  the  reflexes  were  present.  The  legs  and  arms  Mere  de- 
formed, and  locomotion  was  prevented  by  weakness  of  the  muscles.  The 
epiphyses  of  the  bones  were  distinctly  abnormal,  and  the  skiagraph 
showed  marked  absence  of  lime  salts  in  the  bones  of  the  hands.  The 
other  case  was  that  of  a  man,  aged  twenty-three  years,  in  whom  the 
shoulders,  arms,  and  forearms  had  never  developed,  or  there  was  a  retro- 
gression of  development.  The  biceps  jerk  was  absent ;  there  was  no 
disease  of  the  bones  ;  there  was  very  slight  wasting  in  the  left  leg,  only 
detectable  by  measurement.  Several  theories  had  been  advanced  as  to 
the  cause  of  the  condition,  among  others,  bilateral  brachial  palsy  from 
birth,  malposition  in  utero,  etc. ;  but  the  author  was  inclined  to  believe 
that  possibly  the  patient  had  disease  of  the  anterior  horns  of  the  spinal 
cord  in  utero. 

Diseases  and  Deformities  of  the  Spinal  Column. — The  more  common 
pathological  spinal  curvatures  are  scoliosis,  kyphosis,  and  lordosis. 

In  scoliosis  the  patient  should  assume  the  dorsal  decubitus  posi- 
tion. A  skiagram  of  the  kyphotic  patient  is  difficult,  because  the 
plate  cannot  be  properly  approximated  upon  the  part,  necessitating  a 
lateral  view  with  the  patient  on  his  side.  This,  however,  will  not 
afford  a  very  sharp  definition  of  the  shadow,  as  the  plate  is  too  distant 
from  the  part. 

The  same  difficulty  is  encountered  in  lordosis  ;  consequently  in  these 
cases  the  lateral  view  must  likewise  be  employed. 

Torticollis. — "When  the  deeper  muscles  are  diseased,  it  not  infre- 
quently happens  that  caries  of  the  cervical  vertebra  coexists.  Its  pres- 
ence may  be  verified  by  a  skiagram  in  both  the  antero-posterior  and 
lateral  views. 

Pott's  Disease. — It  is  difficult  to  differentiate  the  early  stages  of  Pott's 
disease  from  intercostal  neuralgia,  renal  disease,  empyenia  with  sulxlia- 
phragmatic  abscess,  etc. ;  but  the  skiagram  will  show  the  bodies  of  the 
vertebra)  and  the  interarticular  spaces  to  possess  a  denser  shadow  than 
normal.  In  advanced  cases  the  disintegrated  osseous  tissue  will  present  a 
dark,  dense,  irregular  shadow.  Place  the  patient  in  the  dorsal  decubitus 
position,  have  him  flex  the  knees  so  as  to  straighten  the  spine  as  far  as 
possible  and  thus  bring  it  in  closer  relation  with  the  plate.  The  above 
description  applies  to  any  region  of  the  spine.  Dark  shadows  in  the 
right  iliac  fossa,  often  due  to  the  accumulation  of  gases  in  the  colon, 
must  not  be  mistaken  for  necrosis  of  bone. 

Amputation  Stumps. — The  process  of  healing  can  be  systematically 
followed  in  cases  of  amputation  stumps,  by  noting  the  existence  or  ab- 
sence of  a  fine  layer  of  compact  bony  tissue,  covering  the  medullary  canal, 
and  thus  the  presence  of  a  sequestrum,  interfering  with  the  healing,  can 
likewise  be  detected. 


FIG.  159.— DELAYED  OSSIFICATION  OF  THE  EPIPHYSES.— Patient  55  years  of  age.  Every  bone  deformed. 
Unable  to  walk  since  childhood  and  had  been  in  the  hospital  more  than  30  years.  No  history  of  syphilis,  and 
Dr.  Burr  of  the  Philadelphia  Hospital  believes  the  deformities  to  be  congenital  and  due  to  disease  of  the  spinal 
cord  which  developed  during  foetal  life.  The  epiphyseal  ends  of  the  femora,  tibiae,  and  fibulae  look  spongy  from 
lack  of  ossification.  Articular  surfaces  irregular,  bones  bent  and  pervious  to  the  rays.  The  epiphyseal  lines 
appeared  darker  because  of  excessive  ossification. 


THE  CLINICAL  APPLICATIONS.  L>77 

Resection  of  Joint*. — Before  resecting  a  joint,  the  rays  will  determine 
the  exact  character  of  the  affection,  and  their  application  after  the  wound 
has  been  dressed  will  inform  the  operator  if  the  bones  are  in  the  best 
possible  position. 

Regeneration  of  Bone. — After  removal  of  a  portion  of  bone,  the  peri- 
osteum being  left  intact,  the  formation  of  new  bone  may  be  carefully 
observed,  and  the  surgeon  can  often  determine  if  the  proper  amount  of 
osseous-forming  structure  has  been  deposited. 

VI.   Diseases  and  Tumors  of  the  Soft  Tissues. 

Tumors  of  the  soft  tissues,  being  only  slightly  opaque  to  the  X-rays, 
art-  skiagraphed  with  great  difficulty,  owing  to  the  surrounding  struct- 
ures having  very  nearly  the  same  density.  For  this  purpose  we  employ 
a  hard  tube  with  a  short  exposure,  avoiding  over-exposure  and  super- 
imposition  of  the  shadow  of  the  bone.  This  may  also  be  accomplished 
by  diluting  the  developer  and  producing  a  soft  negative  full  of  details, 
or  by  an  under-developed  negative.  The  detection  of  the  presence  of  a 
tumor  by  a  skiagraph  will  be  dependent  largely  upon  the  location,  size, 
and  consistency,  and  the  technic  employed. 

In  the  order  of  the  density  of  shadows  cast,  tumors  may  be  arranged 
as  follows  : 

Hsematomata  and  Abscesses, 
Myomata, 

Ench<  mdromata, 
Lipomata, 

Fibromata, 
Sarcomata, 

Carcinomata. 

Hazmatomata.—  The  blood  contained  in  a  hreinatorna  is  more  opaque  to 
the  rays  than  the  surrounding  tissue ;  hence  the  shadow  cast  will  be 
darker.  ELematomata  may  be  differentiated  from  abscesses  by  the  fact 
that  the  former  present  a  greater  density,  especially  when  the  blood  is 
coagulated. 

Abscesses  cast  dark  shadows  on  the  negative,  but  not  to  so  great  a 
degree  as  do  the  hoematomata.  In  the  extremities  they  are  easily  diag- 
nosed, but  in  the  abdominal  cavity  or  cranium  they  are  differentiated 
from  other  growths  with  great  difficulty.  Thus,  during  the  past  year  I 
encountered  many  obstacles  in  skiagraphiug  a  condition  at  the  Phila- 
delphia Hospital  that  resembled  appendicitis,  subphrenic  and  hepatic 
abscess.  The  negative  revealed  a  diffused  white  spot  in  the  position 
of  the  lower  region  of  the  liver.  Dr.  Joseph  Hearn  confirmed  the 
diagnosis  by  operation.  Dr.  George  Pfahler  has  recently  reported 
t<>  the  Philadelphia  County  Medical  Society  the  taking  of  a  successful 


278 


ELECTRO-T UK  1 1 A  I '  K  r  T I  ( 'S. 


skiagram  of  a  subphreuic  abscess.  In  January.  1905.  I  diagnosed  skia- 
graphically,  at  the  Philadelphia  Hospital,  a  supposed  hepatic  abscess, 
but  at  a  subsequent  operation  Dr.  Ernest  Laplace  proved  the  affection  to 
be  cancerous. 

Preutz,  of  Jena,  in  a  study  of  234  hepatic  abscesses,  speaks  com- 
mendably  of  the  great  value  derived  from  radioscopy.  Mynmata  and 
fibromata  are  most  difficult  to  skiagraph,  especially  in  the  uterus,  where 
superiniposition  of  the  shadows  of  the  pelvic  bones  interferes  with  a 
differentiation  of  the  tumor  from  the  surrounding  tissues.  Their  shadows 
will  be  easily  recognizable  when  the  neoplasm  is  large,  but  manual  palpa- 
tion will  detect  this  quite  as  readily  as  the  skiagrapher  can  assert  the 
presence  of  this  condition.  It  is  worthy  of  mention  that  skiagraphs  can 
frequently  detect  the  presence  of  myositis  ossificans. 

EnckondromatO)  being  cartilaginous  tumors,  are  difficult  to  skiagraph 
because  of  their  transparency  to  the  rays.  When  the  phalanges  are  thus 
affected,  the  condition  is  clearly  presented  on  the  negative. 

IJ]><»nata  are  differentiated  from  solid  and  cystic  tumors  by  their 
throwing  a  lighter  shadow,  because  fat  is  less  opaque  to  the  rays  than 

the  above  named  neoplasms. 
X-ray  diagnosis  between  a 
chronic  abscess  and  a  lipoina  is 
quite  as  difficult  as  is  the  differ- 
entiation by  clinical  means. 

Sarcomata  ami  corrimmutta 
cannot  be  differentiated  by  their 
skiagraphic  appearance.  They 
both  cast  equally  dense  shadows. 
Tumors  of  the  Brain. — The 
difficulties  encountered  in  diag- 
nosing skiagraph ically  cerebral 
neoplasms  are  due  to  the  super 
imposition  of  the  shadows  of  the 
tumor  and  the  bony  vault,  the 
softened  consistency  of  the  pal  h- 
ological  condition  present,  the 
distance  of  the  shadow  from  the 
plate  occasioned  by  the  arching 
contour  of  the  skull,  and  the 
production  of  secondary  rays 
due  to  the  marked  density  of 

tliis  particular  region.  Formerly  I  employed  the  photographic  plate; 
more  recently  I  used  a  board  made  in  two  sections  that  slide  upon  a  base. 
(Fig.  160. )  The  boards  are  hollowed  out  to  conform  to  the  curvature  of 
the  skull,  and  may  be  so  adjusted  as  to  widen  the  concave  excavation,  and 
thus  accommodate  any  size  of  skull.  In  this  cavity  is  placed  a  double 


FIG.  100.— At  THOR'S  HEAI>  REST.— F  F,  flexi- 
ble photographic  film,  conforming  to  the  sl>!i]>e  of 
the  skull  and  employed  for  locating  foreign  bodies, 
•etc.,  in  the  brain.  A  k-ml  win-  is  run  from  the  glu- 
jM'llii  to  the  inion  and  also  over  the  position  of  the 
fissure  of  Rolando. 


THE  CLINICAL  APPLICATIONS.  279 

coated  gelatine  film,  and  the  patient' s  head  is  accurately  accommodated 
to  the  shape  of  the  cavity.  This  also  insures  steadiness  of  the  part,  so 
very  important  in  this  difficult  procedure.  Localization  can  be  mapped 
out  by  placing  metallic-  wires  over  anatomical  landmarks. 

The  use  of  a  compression  diaphragm,  for  preventing  the  production 
of  secondary  rays,  is  largely  in  vogue  in  Germany,  and  has  lately  become 
popular  in  America,  but  this  is  undesirable,  as  the  area  skiagraphed  is 
too  small  to  allow  of  definite  and  logical  conclusions. 

The  diagnostic  value  of  the  X-rays  in  neoplasms,  abscesses,  clots, 
etc.,  is  less  than  in  instances  of  the  presence  of  foreign  bodies.  Extended 
literature  on  the  subject  is  yet  to  be  written. 

Dr.  Pfahler1  gives  an  interesting  account  of  a  case  of  brain  softening 
occurring  in  the  service  of  Dr.  Charles  W.  Burr.  "  This  case,"  he  says, 
'•  was  one  of  thrombosis  of  the  niid-cerebral  artery,  with  cystic  degenera- 
tion, and  causing  aphasia  and  heniiplegia.  The  examination  was  made 
post  mortem.  The  brain  was  replaced  and  the  skull  and  scalp  closed.  I 
then  made  a  negative  of  the  affected  side  and  also  of  the  opposite  side, 
because  I  believed  that  possibly  the  normal  side  could  be  compared  with 
the  affected  side.  This  case,  however,  demonstrated  that  this  cannot  be 
relied  upon,  for  the  lesion  was  shown  upon  both  negatives,  but  with  much 
more  definite  outline  on  the  affected  side.  The  skiagraph  showed,  above 
the  cerebellum  and  petrous  portion  of  the  temporal  bone,  a  light  area 
which  corresponded  exactly  with  the  outline  of  the  area  of  degeneration. 
This  skiagraph  showed,  also  remarkably  well,  the  convolutions  of  the 
cerebellum. 

"The  second  case  was  also  one  of  Dr.  Burr's,  in  which  an  irreg- 
ular area  of  degeneration  was  found  in  the  distribution  of  the  mid- 
cerebral  artery  and  which  had  caused  hemiplegia.  The  skiagraph 
showed  transparent  areas  which  corresponded  exactly  with  the  area  of 
degeneration." 

Dr.  Pfahler2  believes,  that  u  we  should  be  able  to  show  in  the  skia- 
graph most  large  lesions,  such  as  new  growths,  softening,  hemorrhage, 
and  abscess,  but  that  we  should  never  take  the  responsibility  of  an 
operation  purely  upon  skiagraphic  evidence." 

Dr.  Church,  of  Chicago,3  records  a  case  of  cerebellar  tumor  in  which 
the  Rontgen  rays  were  used  by  Mr.  "W.  C.  Fuchs.  Skiagraphs  of  the 
t  unit  ir  were  obtained.  At  the  autopsy  a  highly  vascular  gliomatous  tumor 
was  found,  the  tumor  being  the  seat  of  several  old  and  recent  hemor- 
rhages, and  also  of  a  recent  clot  of  considerable  size. 

Obici  and  Ballici4  demonstrated  the  presence  of  a  tumor  in  a  boy 
who  died  of  brain  tumor,  the  experiment  being  performed  post  mortem. 

'The  American  Journal  of  the  Medical  Sciences,  December,  1904. 

*Ibid.,  December,  1904. 

slbid.,  February,  1899. 

4  Ri vista  di  Patholog.,  October,  1897,  cited  by  Church. 


280  KI.K(  TIM  )-TI  I  EBAPEUTIC8. 

They  also  experimented  with  tumors  of  different  kinds  placed  in  the 
1  trains  of  cadavers,  and  were  in  sumo  instances  able  to  obtain  localizing 
shadows. 

Oppenheini,1  in  reviewing  the  subject  of  brain  tumors,  remarks  that 
his  attempts  with  the  X-rays  for  diagnostic  purposes  were  unsuccessful, 
although  he  was  enabled  to  determine  that  a  tumor  placed  within  the 
cranium  upon  the  brain  was  distinctly  noticeable. 

Pancoast  and  McCarty 2  conclude  that  the  value  of  the  Bontgen  rays 
in  brain  lesions  is  at  present  dubious. 

Dr.  M.  Benedikt,  of  Vienna.3  described  a  number  of  most  interesting 
conditions  that  were  both  studied  and  skiagraphed  by  Dr.  Kienbock. 
From  a  series  of  cases  related  by  Dr.  Beuedikt  we  cull  the  following  facts 
in  his  own  words:  "Kolar,  M.,  engine-driver.  On  June  6,  1897,  while 
leaning  out  of  the  engine,  he  struck  his  head  against  a  lateral  object. 
He  lost  consciousness,  vomited,  and  was  confined  to  his  bed  for  six  days. 
He  tried  to  resume  his  work,  but  could  not  continue.  On  October  16,  of 
the  same  year,  he  came  for  the  first  time  under  my  observation.  He  com- 
plained of  violent  headaches,  and  his  face  had  the  rigid  expression  of  a 
mask.  On  January  20,  1904,  I  had  two  profile  diagrams  taken  \vith  the 
Rontgen  rays  by  Dr.  Kienbock. 

''When  we  ask  what  pathological  process  we  must  assume  in  this 
case,  the  answer  is  a  pachymeningitis,  especially  haemorrhagica,  with  all 
its  consequences,  also  of  alteration  in  the  osseous  parts.  The  enlarged 
shadow  of  the  osseous  circumference  is  not  principally  the  result  of  thick- 
ening of  the  bones,  but  is  produced  also  by  pachyineningeal  deposits." 

*4  Bornstein  Marcus  met  with  an  accident  Dec.  24,  1903,  while  enter- 
ing a  railway  car  not  yet  lighted.  He  fell  over  a  trunk  and  received  a 
contusion  on  the  tibia  and  on  the  index  finger  of  the  left  hand.  The 
nature  of  this  accident  seemed  to  point  to  a  light  lesion.  To  my  great 
astonishment,  at  the  examination  (Jan.  4,  1904)  serious  symptoms  were 
found.  Standing  with  open  and  closed  eyes  the  patient  oscillated  for- 
ward and  to  the  left  side.  The  supra-  and  infra-orbital  nerves  of  the  left 
side  were  sensitive  to  pressure,  and  the  parietal,  frontal,  and  temporal 
bones  sensitive  to  percussion.  In  these  localities  the  patient  felt  pains 
when  he  walked.  The  turning  of  the  head  excited  pains,  more  toward 
the  left  than  to  the  right  side.  The  cervical  and  dorsal  vertebra  were 
sensitive  to  pressure,  the  sensitiveness  involving  not  only  the  processus 
spinosi,  but  also  the  lateral  walls  of  the  vertebrae  on  the  left  side.  The 
pupil  reflex  was  feeble. 

*•  The  left  arm  and  both  legs  (especially  the  left  one)  were  adynamic. 
The  patellar  reflex  was  feeble,  and  especially  on  the  left  side.  The  left 
ear  was  more  sensitive  to  the  tuning-fork,  from  the  air  and  from  the 

diseases  of  the  Nervous  System,  1900.     Translated  by  K.  Mayer. 
•University  nf  Pennsylvania  Medical  Bulletin.  March,  1903. 
3  The  Archives  of  Physiological  Therapy,  February,  1905. 


THE  CLINK  A  L  APPLICATIONS.  281 

lt<i nes  of  the  head.  I  was  more  astonished  when  Professor  Reuss  found 
beginning  bilateral  papillitis  n.  optici.  The  range  of  vision  was  much 
diminished  concentrically,  and  in  the  left  eye  there  existed  a  complete 
defect  of  vision  in  an  inferior  and  superior  sector. 

"In  this  case  the  diagnosis  was  justifiable  that  there  were  serious 
anatomical  intracranial  lesions,  and,  as  the  case  was  a  recent  one,  also 
blood  effusions.  Radiographs  confirmed  this  diagnosis." 

I  have  successfully  skiagraphed  a  blood  clot  in  the  brain,  and  I  can 
do  no  better  than  quote  the  words  of  the  late  Dr.  F.  Savary  Pearce, 
whose  intense  devotion  to  neurology  and  whose  searching  inquiry  into 
the  pathological  manifestations  of  brain  lesions  made  his  word  authori- 
tative. In  his  article  u Epiphenomena  of  Cerebral  Hemorrhage/'1  he 
says,  ''We  would  like  to  mention  the  possibility  of  the  X-ray  being  a 
favorable  adjunct  toward  determination  of  a  blood  clot  within  the  brain'or 
not,  as  a  point  in  diagnosis  between  hemorrhage  or  thrombosis  and  this 
confusing  class  of  Bright's  palsies.  In  a  case  coming  to  autopsy  at  the 
Medico-Chirurgical  Hospital  ten  days  ago.  Dr.  M.  K.  Kassabian  had 
been  fortunate  enough  to  find  what  he  thought  was  a  '  shadow '  of  the 
thrombotic  area  in  the  left  lenticulo-striate  area  region,  and  this  proved 
to  be  so  at  the  post-mortem  examination.  In  this  case,  however,  there 
was  no  complication  of  nephritis  in  making  the  clinical  diagnosis." 

During  1904  and  1905,  I  skiagraphed  at  the  Philadelphia  Hospital 
a  series  of  cerebral  cases  in  the  services  of  Drs.  AN'.  AV.  Keen,  F.  X. 
Dercum,  and  Charles  AV.  Burr.  Realizing  the  imperfection  resulting 
from  the  lightness  of  the  shadow  found  in  skiagraphing  brain  tissue,  I 
took  two  skiagrams  of  suspected  conditions  and  applied  to  the  negatives 
obtained  the  principles  of  stereo- skiagraphy.  The  superimposition  of 
the  two  views  thus  derived  resulted  in  a  clear-cut  picture  of  the  part 
under  investigation. 

Recently  I  skiagraphed  a  cerebral  case  at  the  Philadelphia  Hospital. 
The  patient's  skull  was  bandaged,  thus  concealing  the  presence  of  any 
abnormality.  I  was  ignorant  of  his  clinical  history.  AVhen  the  plate 
was  developed,  I  noticed  in  the  motor  region,  a  light  area,  the  size  of  a 
goose's  egg.  I  then  went  to  the  ward  to  inquire  as  to  the  patient's  symp- 
toms. I  found  that  this  special  area  was  the  one  complained  of;  the 
ivsult  of  a  trauinatism,  which  manifested  itself  in  a  slight  paraplegia  of 
the  opposite  side.  This  was  undoubtedly  an  ecchymosis  of  the  cerebral 
meninges.  A  false  diagnosis  was  not  probable,  as  there  was  no  wet  dress- 
ing or  iodoform  employed,  no  exudation  of  serum  or  blood,  and  likewise 
no  pressure  on  the  plate  that  might  simulate  such  a  diseased  area.  Sub- 
sequent examinations  failed  to  reveal  the  affected  region,  although  the 
skiagraph  was  taken  under  the  same  circumstances.  Ultimately  the 
patient  got  well,  showing  the  ecchymosis  (exudate)  was  absorbed. 

1  American  Medicine,  Aug.  9,  1902. 


ELECTRO-THERAPEUTICS. 


l>rpoxH#  in  Glumlx.  —  The  shadow  thrown  by  these  deposits 
is  in  some  regions  of  the  body  dense  enough  to  be  mistaken  tor  calculi. 
If  there  be  an  abscess  cavity,  sinus,  or  fistula,  its  depth  and  extent  may 
be  sufficiently  ascertained  by  introducing  either  a  probe,  a  packing  of 
iodoform  gauze,  or  a  rubber  drainage  tube,  and  taking  a  skiagram  while 
the  introduced  substance  is  inxitu. 

Empyema  and  pleural  effusions  will  be  treated  of  when  discussing 
diseases  of  the  thoracic  organs. 

Enlarged  mediastiual  glands,  calcified  glands,  and  bronchial  glands 
are  often  visible. 

VII.  The  Articular  System. 

.  In  the  normal  joint,  the  cartilage  being  transparent  to  the  rays,  the 
negative  will  show  the  inter-articular  space  black,  but  it  will  appear 
white  on  the  skiagraph.  The  articular  extremities  of  the  bones  will  look 
smooth.  In  adjusting  the  tube,  part,  and  plate,  care  must  be  taken  to 
see  that  the  rays  fall  directly  upon  the  joint;  for  if  this  precaution 
be  not  taken,  there  will  result  an  overlapping  of  the  shadows  of  the 
articular  extremities,  the  latter  leading  to  a  confusion,  and  causing  a 
possible  error  between  a  diagnosis  of  the  true  condition,  ankylosis,  and 
subluxatiou. 

As  muscles,  tendons,  and  ligaments  are  slightly  less  opaque  to  the 
rays  than  are  the  bones,  the  tearing  off  of  any  of  these,  as  in  some  sprains, 
can  sometimes  be  shown  on  the  skiagram,  provided  that  the  shadow  falls 
particularly  on  the  muscular  field,  and  that  the  negative  is  full  of  details, 
the  result  of  good  technic. 

A.  DISEASES  OF  THE  JOINTS. 

Acute  Arthritis.  —  In  this  affection  the  skiagram  reveals  nothing  in  the 
early  stage,  save  a  slight  cloudiness  or  haziness  at  the  inter-articular 
space,  due  to  congestion.  Later  this  haziness  increases,  and  if  pus  be 
present,  the  shadow  cast  on  the  negative  will  be  darker,  as  this  is  less 
opaque  to  the  passage  of  the  rays  than  is  serum.  If  the  arthritis  con- 
tinue for  a  few  months,  the  inflammation  will  extend  to  the  articu- 
lar ends  of  the  bone,  and  they  will  be  more  opaque  to  the  rays,  and 
consequently  appear  white  on  the  negative. 

Acute  and  Chronic  Articular  Rhi-nmaiixm.  —  The  acute  stage  is  identical 
with  the  description  given  under  acute  arthritis.  When  this  condition 
assumes  the  chronic  form,  the  skiagram  will  show  destruction  of  the  ar- 
ticular ends  of  the  bones,  causing  displacements  of  the  opposed  bony 
surfaces  and  the  attendant  deformities. 

Gout.  —  In  this  disease  the  tophi  (which  are  composed  of  sodium 
urate)  are  transparent  to  the  rays.  Yet  peri-articular  shadows  of  the 
tophi  are  often  visible  in  the  digits. 


THE  CLINICAL  APPLICATIONS.  283 

Tuberculous  Arthritis.  (Fig.  Kil.) — The  early  stages  of  tuberculous 
arthritis  are  most  difficult  to  distinguish  from  other  arthritic  conditions. 
But  as  soon  as  the  bone  becomes  involved  the  shadow  on  the  negative  will 
be  identical  with  the  appearance  of  tuberculosis  of  bone  previously  de- 
scribed ;  but  with  abscess  formation,  the  dark  spots  on  the  skiagram  will 
reveal  the  true  nature  of  the  malady.  When  destruction  of  the  soft  parts 
of  the  joint  occurs  with  subsequent  absorption  of  the  head  of  the  bone, 
sequestra  are  formed,  resulting  in  great  distortion. 

Cojcalgia. — In  the  incipient  stage  any  haziness  in  the  interarticular 
space,  iu  comparison  with  the  unaffected  side,  is  indicative  of  changes 
in  the  syuovial  membrane  of  the  joint, — this  is  likewise  true  of  the 
epiphyseal  line. 

Lovett  and  Brown,  iu  a  most  elaborate  research,1  arrived  at  these 
conclusions:  "The  earliest  changes  observed  radiograph ically  in  hip 
disease  are,  first,  diminution  in  the  density  of  the  shadow,  and  second,  a 
relative  diminution  in  the  size  of  the  shadow  cast  by  the  affected  bone ; 
in  other  words,  atrophy  of  the  bony  substance. 

''The  best  radiographic  evidence  is  considered  to  be  bony  thickening, 
indicated  by  a  shadow  projecting  inward  from  the  pelvic  side  of  the 
acetabulum ;  the  head  and  neck  of  the  femur  also  may  show  this 
evidence. 

"Decreased  radiability,  observed  as au  indefinite,  cloudy  appearance, 
which  involves  not  only  the  bony  medulla,  but  the  cortex  and  periosseous 
structures  as  well,  is  frequently  seen.  This  cloudiness  was  found  to  be 
due  to  the  presence  of  thick  serum,  pus,  or  finely  divided  detritus,  and  is 
apt  to  be  misleading  if  depended  upon  to  the  exclusion  of  other  indica- 
tions. It  was  sometimes  observed  where  the  inflammatory  process  was 
extra- articular,  as  iu  abscess  of  the  groin. 

"Erosion  of  the  bone  substance,  when  present,  is  usually  clearly 
evident  on  the  plate,  but  is  not  of  itself  conclusive  evidence  that  hip- 
joint  disease  is  present." 

Loose  bodies,  such  as  displaced  or  detached  cartilage,  are  difficult  of 
detection  because  of  their  transparency.  If  their  shadows  are  superim- 
posed with  those  of  the  bones,  recognition  is  of  course  impossible,  as  on 
the  shadow  of  muscles,  their  detection,  at  times,  is  possible.  Small  sesa- 
iiioid  bones,  which  may  simulate  foreign  bodies,  can  also  be  skiagraphed 
in  or  around  a  joint. 

Coxa  Vara. — "The  neck  of  the  femur  varies  in  length  and  obliquity 
at  various  periods  of  life  and  under  different  circumstances.  In  infancy 
the  angle  is  widest  and  becomes  lessened  during  growth,  so  that  at  pu- 
berty it  forms  a  gentle  curve  from  the  axis  of  the  shaft.  In  the  adult  it 
forms  an  angle  of  about  130°  with  the  shaft,  but  varies  in  inverse  propor- 
tion to  the  development  of  the  pelvis  and  stature.  In  consequence  of  the 

1  New  York  Medical  Journal,  January  28,  1905. 


284  ELECTRO-THERAPEUTICS. 

prominence  of  the  hips  and  widening  of  the  pelvis  in  the  female,  the  neck 
of  the  thigh  bone  forms  more  nearly  a  right  angle  with  the  shaft  than  it 
does  in  man."  (Gray.) 

Skiagraphy  in  cases  of  coxa  vara  reveals  the  true  clinical  condition. 
(Fig.  162.)  It  is  found  that  the  axis  of  the  neck  to  the  shaft  has  materi- 
ally changed  its  angle,  that  the  affection  is  non-tuberculous,  and  that  the 
trochauter  has  changed  from  its  normal  position  to  a  higher  plane.  In 
skiagraphing  this  condition,  inversion  and  eversion  of  the  feet  must  be 
vigorously  guarded  against.  This  is  best  accomplished  by  securely  bind- 
ing both  feet  in  the  position  of  a  right  angle  to  the  leg.  A  plate  large 
enough  to  include  both  hips  must  be  employed  ;  the  patient  must  lie  ab- 
solutely flat  on  his  back,  with  the  tube  placed  over  the  pubic  symphysis 
in  the  median  line.  Some  operators  prefer  the  ventral  to  the  dorsal  de- 
cnbitus  position.  Of  course,  the  position  assumed  will  slightly  vary  the 
length  of  the  neck  of  the  bone.  Consequently  the  necessity  of  compari- 
son between  the  affected  and  the  normal  sides. 

Genu  valgum  is  the  result  of  overgrowth  of  the  inner  condyle  and  an 
incurvation  of  the  femoral  shaft.  The  X-rays  will  show  the  amount  and 
the  angle  of  deformity,  and  also  any  alterations  in  the  relaxation  and 
elongation  of  the  ligaments  of  the  knee-joint. 

Genu  varum  is  the  opposite  of  geuu  valgum,  and  in  these  cases  the 
X-rays  will  also  furnish  the  operator  with  complete  clinical  data. 

Deformities  of  the  foot,  including  talipes  in  its  various  forms,  dis- 
placements of  the  toes,  and  deformities  of  the  hands  and  digits  can  be  most 
advantageously  studied  by  corroborating  the  facts  of  clinical  experience 
with  the  X-rays. 

B.  ARTHROPATHIES. 

In  the  early  stages,  arthropathies,  as  manifested  in  tabes  (Fig.  163), 
present  a  haziness  in  the  joint,  identical  with  the  appearance  evidenced 
in  other  forms  of  arthritis.  Later  the  interarticular  space  becomes  more 
hazy,  the  periarticular  structures  are  destroyed,  the  ends  of  the  bones 
irregular  and  nodular,  with  rarefaction  of  the  osseous  tissue  and  possibly 
complete  disappearance  of  the  bone.  In  some  instances,  in  place  of  rare- 
faction, we  find  thickening  or  eburnation,  with  the  projection  of  bony 
excrescences. 

Syringomyelia. — Several  authorities1  state,  that  in  syringomyelia  there 
is  progressive  destruction  of  the  joints,  greater  in  extent  than  is  noticed 
in  tabes,  but  marked  by  an  absence  of  bony  excrescences.  Mor van's 
disease,  often  associated  with  syringomyelia  and  characterized  by  the 
formation  of  painless  felons,  shows  skiagraph ically  an  irregular  appear- 
ance and  a  thickening  of  the  bone,  frequently  with  the  presence  of 
sfini(>stra.  Pulmonary  tuberculosis  and  general  systemic  diseases  may 

1  Bouchard,  "  Traite  de  Kadiologie  Mcdicah-,"  1!«>4. 


FIG.  161.— TUBERCULOUS  ARTHRITIS  OF  THE  KNEE-JOINT.— The  left-hand  picture  shows  tubercu- 
lous arthritis  of  the  knee-joint ;  4—5  indicates  the  distended  capsular  ligament ;  3,  a  narrowing  of 
the  inter-articular  space ;  1  and  2  show  the  changed  character  of  the  epiphyses.  The  skiagraph  was 
taken  after  the  limb  had  been  braced  for  two  months.  Right-hand  picture  shows  the  normal  limb. 
(Case  of  Dr.  J.  K.  Young.) 


FIG.  162.— COXA  VABA.— As  a  result  of  tuberculosis  of  the  knee-joint.    C,  cast  around  the 
right  knee-joint.     (Case  of  Dr.  James  K.  Young.) 


FIG.  163.— Arthropathies  of  the  knee-joint,  in  a  patient  with  tabes  dorsalis. 
(Case  of  Dr.  Chas.  K.  Mills.) 


FIG.  164.— Penny  in  the  oesophagus. 


THE  CLINICAL  APPLICATION'S.  285 

also  show  arthropathies,  but  will  not  show  the  destruction  of  the  articular 
ends  of  the  bones,  but  there  will  be  revealed  a  periarticular.  semi-opaque 
condition. 

VIII.   Foreign  Bodies  and  their  Localization. 

In  nothing  have  the  X-rays  proved  themselves  of  more  incalculable 
service  than  in  the  detection  and  localization  of  foreign  bodies.  Prior 
to  the  discovery  of  this  priceless  diagnostic  agent,  the  surgeon  found 
himself  helpless  in  cutting  down  upon  a  supposed  embedded  substance, 
but  with  determination  born  of  forlorn  hope,  too  often  he  pursued  an 
erroneous  course,  only  to  find  that  disappointment  and  at  times  serious 
infections  were  the  rewards  of  his  endeavors. 

By  the  rays  the  skiagrapher  learns  not  only  the  position  of  a  foreign 
body,  its  variety,  size,  and  shape,  but  also  the  extent  of  damage  incurred. 

A.  MILITARY  SURGERY. 

The  X-rays  have  been  especially  useful  in  military  surgery.  Dr. 
Haughton  has  said,  "that  the  X-raj'S  have  furnished  the  army  surgeon 
with  a  probe  which  is  painless,  which  is  exact,  and,  most  important  of 
all,  which  is  aseptic." 

In  1897  the  X-rays  were  for  the  first  time  successfully  used  in  the 
Grace-Turkish  war.  It  was  there  demonstrated  that  they  were  an  invalu- 
able adjunct  in  military  surgery,  and  since  that  time  improvements  have 
been  made  in  the  apparatus  for  trials  in  future  field  encounters. 

The  X-rays  were  also  employed  with  marked  success  by  Surgeon- 
Major  Beevor  on  the  Indian  frontier,  during  the  Chitral  Campaign  in  1898. 

Of  no  less  importance  were  the  experiences  of  Major  Battersby,  who 
had  charge  of  the  Eontgen  apparatus,  while  campaigning  in  the  Soudan 
a  number  of  years  ago.  Following  the  battle  at  Omduruian,  121  wounded 
British  soldiers  were  brought  to  Abadith,  21  of  whom  could  not  have  had 
their  condition  correctly  diagnosed  without  X-ray  examination. 

In  the  words  of  Captain  \V.  C.  Borden,  assistant  surgeon  in  the 
United  States  Army:1  "The  use  of  the  Eontgen  rays  has  marked  a 
distinct  advance  in  military  surgery.  It  has  favored  conservatism  and 
promoted  the  aseptic  healing  of  bullet  wounds  made  by  lodged  missiles, 
in  that  it  has  done  away  with  the  necessity  for  the  exploration  of  wounds 
by  probes  or  other  means,  and  has  thus  obviated  the  dangers  of  infection 
and  additional  traumatism  in  this  class  of  injuries.  In  gunshot  fractures 
it  has  been  of  great  service  from  a  scientific  point  of  view,  by  showing 
the  character  of  the  bone  lesions,  the  form  of  fracture,  and  the  amount  of 
bone  comminution  produced  by  the  small  calibre  and  other  bullets, — 

1  The  Use  of  the  Runtgen  Rays  by  the  Medical  Department  of  the  United  States 
Army  in  the  War  with  Spain. 


ELK(  TK<  )-TH  BEAPBUTIC8. 

conditions  which  could  not  have  been  otherwise  determined  in  the  living 
body." 

Nicholas  Senu  writes  that  the  expectations  as  to  the  diagnostic  value 
of  the  X-rays  in  military  surgery  were  actually  realized  in  the  Spanish- 
American  War.  He  states  that  foreign  bodies  were  located,  fractures 
ascertained,  and  other  surgical  conditions  studied,  without  subjecting  the 
patient  to  pain  or  any  danger  from  infection. 

Mr.  Clinton  Dent,1  special  war  correspondent  in  South  Africa,  speaks 
interestingly  of  injuries  by  Mauser  bullets.  If  the  dense  part  of  the  long 
bone  is  hit  by  a  bullet  of  the  Mauser  type,  there  is  a  drilling,  compli- 
cated by  fracture.  The  extent  of  the  injury  depends  upon  the  angle  at 
which  the  bullet  strikes  the  bone,  upon  the  velocity  of  the  bullet,  and  to 
some  extent  upon  the  age  of  the  person.  Mr.  Dent  also  observes,  "that 
a  line  drawn  between  the  apertures  of  entrance  and  exit  does  not  afford  a 
reliable  clue  of  the  course  that  the  bullet  has  followed/'  He  also  states 
that  fractures  with  a  drilling  of  the  tibia  and  the  upper  and  lower  ends 
of  the  humerus  and  radius  are  common. 

Major  Matignon,  in  reference  to  the  Eusso-Japanese  war,  describes 
at  length2  the  installation  of  an  X-ray  apparatus  in  the  Fifth  Division  of 
the  Japanese  army  in  Manchuria.  This  apparatus  consisted  of  a  Ruhui- 
korff  coil,  30  cm.  long  and  12  cm.  in  diameter,  with  a  spark-producing 
power  of  from  15  to  18  cm.  The  tube  was  bi-anodic  and  20  cm.  long. 
The  current  was  supplied  by  a  dynamo,  energized  by  hand-power.  Two 
persons  were  enabled  to  bring  about  sufficient  velocity  to  produce  the 
desired  current  by  means  of  gearing.  A  portable  dark  room  was  pro- 
vided, and  Major  Matiguon  remarks:  "I  was  able  to  discern  clearly 
the  fractures  and  the  presence  of  foreign  bodies  in  the  hand  and  in  the 
arm."  He  further  states  that  the  use  of  accumulators  and  their  bur- 
densome construction  can  thus  be  readily  dispensed  with. 

B.  VARIETIES  OF  FOREIGN  BODIES. 

These  may  be  transparent,  translucent,  or  opaque  to  the  rays. 

The  transparent  include  such  substances  as  splinters  of  wood,  pieces 
of  coal,  diamonds,  paper  wads,  leather,  clothing,  etc. 

The  translucent  include  a  fragment  of  porcelain,  paste  diamonds, 
small  fish  bones,  other  small  bones,  seeds  of  fruits,  small  pieces  of 
glass,  etc. 

The  opaque  include  metallic  substances,  such  as  bullets,  coins,  nails, 
buttons,  pins,  needles,  jack-stones,  marbles,  and  dice  ;  also  surgical  dress- 
ings,— dusting  powders  (e.  <?.,  bismuth,  iodoform),  lead-water  and  lauda- 
num, corrosive  sublimate,  dermatol,  permanganate  of  potassium,  etc., 
hard-rubber  tubes,  and  iodoform  gauze. 

1  British  Medical  Journal,  April  21,  1900,  p.  969. 
Archives  d'Electricite  Mcdicale,  June  2o,  1906. 


THK  CLINICAL  APPLICATIONS. 


287 


The  table  In-low  shows  the  relative  transparency  of  equal  thicknesses 
of  various  substances  .water       1  i  as  found  by  Bottelli  and  Garbasso.1 

TAP.LK  <>F  PEUMEAP.ILITY  OF  RnNTUKA  RAYS. 


MATERIAL. 

Sl'Kcmr 
(iKAVITY. 

TRAN- 

1-AKEM  V. 

MATERIAL. 

SPECIFIC 
GRAVITY. 

TRANS- 

I'AKENt  Y. 

Pine  wood    

(i:>t; 

2.21 

Iron      

7.87 

0.101 

Walnut          

0.66 

1  50 

Chalk  

2  7 

0.330 

Parattin  .        

0.874 

1.12 

Antimony  

6  7 

0  126 

Rubber  (pure  gum).. 

093 

1  10 

Nickel     "        

867 

0095 

Wax  

097 

1  10 

Brass 

8  70 

0093 

Stearine                   

097 

094 

Cadmium 

8  69 

0090 

Paste  board              .... 

080 

Copper 

8  96 

0084 

Ebonite  

1.14 

0.80 

Bismuth  

US" 

0.075 

Woollen  tissue  

0.76 

Silver  

105 

0.070 

(  /eUoloid     

0.76 

Lead  

11  38 

0.055 

Whalebone    

074 

Palladium                  .  . 

11.3 

0.053 

Silk        

074 

Mercury 

13  50 

0044 

Cott.m  

0.70 

Gold  

19.36 

0.030 

Charcoal    (hardwood) 

0.63 

Platinum  

22.07 

0.020 

Starch  

0.63 

Ether  

0.713 

1.37 

Sugar  

1.61 

0.60 

Petroleum  

0.836 

1.28 

Bone      

19 

056 

Alcohol  

0793 

1.22 

Magnesium  . 

1  74 

1  1  .->(  ) 

Amyl  alcohol  .... 

1.20 

Coke                 .    .  . 

048 

Olive  oil 

0915 

1.12 

<  ilue  

0.48 

Benzol  

0.868 

1.00 

Sulphur  

1.98 

047 

WTater  

1.000 

1.00 

Lead  plaster  

0.40 

Muriatic  acid  

1.260 

0.86 

Aluminium  

2.67 

038 

Glycerin  ...   .       .... 

1.240 

0.76 

Talc  (  soapstone  )  
Glas^      ... 

2.6 
26 

0.35 

034 

Carbon  disulphide.  .  . 
Nitric  acid  

1  293 
1.420 

0.74 
0.70 

Tin                 

0118 

Chloroform    

1.525 

0.60 

Zinc   

720 

0.116 

Sulphuric  acid  

1.841 

0.50 

C.   F<>KKK;N  BODIES  ix  THE  DIGESTIVE,  KESPIRATORY,  AND  GENITO- 
VRINARY  TRACTS. 

(Esophagus. — Foreign  bodies  in  this  region  can  be  detected  by  the 
fluoroscope  and  skiagram,  and  should  be  examined  in  both  positions.  I 
recently  skiagraphed  a  child  with  a  penny  lodged  in  the  oesophagus,  as 
shown  in  Fig.  164. 

Segond2  reports  a  case  where  a  tooth-plate  had  accidentally  been 
swallowed  and  lodged  in  the  oesophagus.  It  was  located  by  the  X-rays  at 
the  region  of  the  supra-sternal  concavity,  and  extracted  by  external 
oesophagotoiny.  A  hook-like  projection  of  the  plate  forced  its  way  into 
the  mucous  and  submucous  coats  of  the  organ,  requiring  repeated 
fluoroscopic  examinations  before  extraction  was  achieved. 

Mr.  Ballance,  of  St.  Thomas  Hospital,  London,  says  that  by 
means  of  a  fluoroscopic  examination,  a  hat-pin  was  demonstrated  in  the 

1  Bolletino  della  Societa  Photografica  Italiana,  1897. 
-  Lyon  Mi'dicale,  Auguet  5,  1898. 


l>ss  ELECTRO-THERAPEUTICS. 

oesophagus  of  an  infant  fifteen  mouths  old.  It  had  travelled  to  the  lower 
third  of  the  tract,  where  it  had  fastened  itself.  A  gastrotomy  was 
performed  and  the  pin  removed. 

Dr.  Nathan  Raw 1  reports  the  swallowing  of  a  tooth-plate  by  a  luuatic. 
The  foreign  body  had  descended  to  a  level  just  slightly  below  the 
inter-clavicular  notch.  The  fluoroscope  revealed  the  exact  position,  and 
also  showed  the  plate  with  its  longest  diameter  lying  parallel  with  the 
transverse  axis  of  the  oesophagus. 

Stomach. — Almost  every  variety  of  foreign  body  is  found  in  the  stom- 
ach, but  the  movement  of  that  organ  makes  detection  difficult.  In  skia- 
graphing  the  stomach,  the  patient  should  be  placed  in  the  ventral 
posture.  Previously,  he  should  have  been  cautioned  against  ingest inu 
food  and  drink,  as  the  former  will  increase  the  density  of  the  shadows 
and  the  latter,  in  addition,  offers  an  opacity  to  the  rays.  The  foreign 
bodjr  is  invariably  found  at  the  pyloric  orifice. 

Several  years  ago,  at  the  clinic  of  the  Medico-Chirurgical  Hospital  I 
demonstrated,  by  means  of  a  skiagram,  the  presence  of  tacks,  nails,  and 
blades  of  pen-knives  in  the  stomach  of  the  "ostrich  man." 

W.  S.  Halsted2  publishes  a  radiogram  of  a  juggler's  stomach,  from 
which  he  removed  208  foreign  bodies,  including  20  links  of  dog-chain, 
8  pieces  of  china,  7  knife-blades,  54  nails,  and  35  wire  nails. 

Diamonds  and  small  stones,  being  transparent  to  the  rays,  defy  detec- 
tion. Sometimes  diamond  thieves  have  swallowed  the  stones,  but  the 
latter  could  not  be  found  either  by  fluoroscopy  or  skiagraphy.  In  many 
of  the  mints,  suspected  employes  are  subjected  to  X-ray  examinations 
to  detect  the  presence  of  stolen  coins  in  the  stomach. 

Intestines. — In  the  intestines  foreign  bodies,  such  as  coins,  pins,  nails, 
Murphy  buttons,  etc.,  can  be  seen  gradually  to  traverse  the  bowel.  The 
peristaltic  action  of  the  intestines  often  interferes  with  this  detection. 
The  skiagrapher  is  further  hindered  in  the  cases  of  children,  their  crying 
and  moving  presenting  an  additional  obstacle.  So  long  as  the  foreign 
body  is  being  moved  by  peristalsis,  the  surgeon  should  not  attempt  to 
operate.  It  requires  three  or  four  days  for  a  foreign  body  to  be  dis 
charged.  Skiagraphy  is  of  special  value  in  impaction  of  the  rectum 
by  foreign  bodies,  so  commonly  found  in  the  hysterical  and  insane  ;  it  is 
also  of  utility  in  detecting  foreign  bodies  in  the  appendix. 

Larnyx,  Trachea,  and  Bronchi. — The  foreign  bodies  lodged  here  :n<- 
identical  with  those  found  in  the  stomach.  The  method  of  examination 
is  likewise  similar. 

Genito-Vrinary  Trad. — Almost  every  conceivable  variety  of  foreign 
body  is  to  be  found  in  the  urethra  and  bladder  of  the  male,  and  in  the 
vagina,  uterus,  and  bladder  of  the  female.  Recently  I  examined  a  pat  icnt 

'The  Liverpool  Medico-Chirurgical  Journal,  September,  1901,  p.  345. 
1  Johns  Hopkins  Hospital  Reports,  1900,  vol.  ix.  p.  1054. 


THE  CLINICAL  APPLICATIONS.  289 

for  fractures  of  the  femora,  but  instead  I  discovered  a  forgotten  pessary. 
Forgotten  pessaries  have  often  been  detected  by  the  X-rays,  when  the 
cause  of  the  suffering  baffled  the  skill  of  the  attending  physician. 

Foreign  Bodies  Entering  front  Without. — These  include  bullets,  needles, 
cinders  in  the  eye,  broken  ends  of  instruments,  etc.  In  surgery  we  have, 
in  addition  to  the  retention  of  instruments  in  the  cavity  of  the  wound,  a 
slipping  in  of  a  forgotten  section  of  drainage-tube,  and  the  closure  of  a 
wound  without  removal  of  iodoform  gauze,  etc. 

D.  THE  X-RAYS  ix  OPHTHALMOLOGICAL  SURGERY. 

Foreign  Bodies  in  the  Eye. — The  use  of  the  X-rays  in  ophthalmology 
is  principally  confined  to  the  detection  and  localization  of  foreign  bodies 
in  the  eye.  Dr.  Van  Duyse  was  perhaps  the  first  to  perform  experiments 
for  locating  foreign  bodies  in  the  eye,  and  in  March,  1896,  he  communi- 
cated his  results  to  members  of  the  Medical  Society  of  Gand. 

His  first  work  consisted  in  the  introduction  of  a  small  bullet  into  the 
eye  of  a  rabbit,  carefully  pushing  it  up  posteriorly  to  the  iris.  He  pro- 
duced an  exophthalmos,  and  by  slipping  under  the  exophthalmic  globe  a 
small  sensitive  plate,  he  was  able  to  define  a  shadow  of  the  contained 
foreign  body.  By  another  expriment  he  proved  that  metallic  bodies  in 
the  anterior  chamber  could  be  very  easily  demonstrated  by  placing  a 
sensitive  film  of  proper  shape  and  size  between  the  eyelids  at  the  inner 
canthus  and  allowing  the  rays  to  penetrate  the  globe  from  the  temporal 
side. 

Dr.  Leukowitsch1  detailed  his  experiments  and  results  on  sheep's 
eyes,  with  the  use  of  two  tubes.  He  contended,  however,  that  better  re- 
sults had  been  obtained  by  the  use  of  one  tube  only.  In  experimenting 
on  the  human  eye,  he  employed  small  sensitive  plates,  semicircular  in 
shape,  thus  permitting  the  largest  possible  area  being  introduced  at  the 
inner  angle  of  the  eye  opposite  the  lacrymal  bone.  A  large  part  of  the 
eyeball  can  readily  be  brought  within  easy  range  of  the  rays  by  simply 
rolling  the  eyeball.  Rotation  of  the  ball  caused  a  point  of  fixation, 
which  was  obtained  by  employing  a  glass  indicator  bent  into  two  right 
angles,  a  short  and  straight  terminal  so  placed  as  to  point  exactly  to  the 
antero-posterior  axis  of  the  cornea's  centre. 

Dr.  Max  J.  Stern,  at  the  Philadelphia  Poly  clinic,2  proved  that  a 
foreign  body  in  any  part  of  the  eyeball  could  be  shadowed  on  the  plate  at 
the  side  of  the  head,  and  radiographed  four  patients  with  steel  in  the  eye- 
ball. He  determined  the  approximate  positions  of  the  metal  in  the  eye 
from  a  study  of  the  shadow  of  the  body  in  relation  to  the  shadows  on  the 
plate  of  the  orbital  bones ;  but  the  variation  in  the  position  of  the  eye- 
ball in  the  orbit  rendered  this  method  liable  to  considerable  error. 

'The  Lancet,  August  15,  1896. 
2  Trans.  Amer.  Oph.  Soc.,  1896. 
19 


290  ELECTRO-THERAPEUTICS. 

In  February,  1897,  Drs.  Ring  and  Hansell  each  reported  one  case, 
and  Dr.  de  Schweinitz  two  cases  of  steel  particles  in  the  vitreous  located 
by  the  X-rays.  In  one  of  these  cases  two  previous  unsuccessful  attempts 
had  been  made  to  extract  the  steel,  and  it  was  only  after  the  radiographs 
indicated  its  approximate  position  that  it  was  extracted  by  the  magnet. 
These  cases  were  probably  the  first  that  demonstrated  that  the  bony 
walls  of  the  orbit  and  the  coats  of  the  eye  were  permeable  tq  the  rays. 
By  comparison  of  the  shadow  of  the  metal  with  that  of  the  margin  of  the 
malar  process  of  the  superior  maxillary  bone,  and  the  knowledge  of  the 
relation  of  the  Crookes  tube  to  the  sensitive  plate,  the  location  of  the 
foreign  body  could  be  easily  demonstrated. 

Dahlefeld  and  Pohrt1  report  that  good  records  were  obtained  of 
small  fragments  of  wire  and  small  shot  that  had  previously  been  intro- 
duced into  the  orbits.  Their  method  of  detection  consists  in  placing  a 
focus  tube  on  the  opposite  side  of  the  head  (10  to  15  mm.  distant  from 
the  temple)  and  a  sensitive  plate  against  the  temple  corresponding  to  the 
affected  side. 

Fridenberg2  and  Friedman*  both  made  two  exposures  of  the  eye 
and  orbit  at  right  angles  to  each  other,  while  Stockl*  used  pieces  of 
lead,  fastened  at  various  points  around  the  orbital  margin,  from  which  to 
measure  the  situation  of  the  foreign  body.  Leonard  made  a  number  of 
exposures  to  give  a  series  of  triangles  to  locate  the  body. 

For  the  want  of  space,  I  shall  include  only  those  methods  which  in 
my  experience  have  been  found  most  useful. 

Dr.  "Wm.  M.  Sweet5  was  the  first  to  devise  an  accurate  method  of 
localization,  employing  for  this  purpose  a  plate-holding  apparatus,  fixed 
to  the  side  of  the  head  on  the  injured  side,  the  fixed  points  of  measure- 
ment consisting  of  two  ball-pointed  rods,  adjusted  at  a  known  distance 
from  the  centre  of  the  cornea. 

In  describing  the  method,  Sweet6  says:  "The  determination  of  the 
location  of  pieces  of  metal  in  the  eye  or  in  the  immediately  adjacent 
tissues  by  means  of  the  Rontgen  rays  demands  that  the  shadow  of  the 
foreign  body  as  shown  on  the  radiograph  be  studied  in  relation  to  the 
shadows  of  at  least  two  opaque  objects  of  known  position.  The  method  of 
judging  the  approximate  position  of  the  body  in  the  eye  from  the  rela- 
tion of  its  shadow  on  the  photographic  plate  to  the  shadows  cast  by  the 
bones  of  the  orbit  is  less  accurate  than  the  method  by  triangulation,  even 
when  carried  out  by  making  two  exposures  upon  the  same  plate  with  the 
tube  in  different  positions,  or  by  making  several  separate  exposures." 

1  Deutsche  medicinische  Wochenschrift,  No.  18,  1897. 

2  Medical  Record,  May  15,  1897. 

3  Klin.  Monateblatt,  Oct.  1897. 

4  Wiener  kl;n.  Wochen.,  No.  7,  1898. 

5  Trans.  Amer.  Ophth.  Society,  May,  1897. 

6  Diseases  of  the  Eye,  by  Hansell  and  Sweet. 


THE  CLINICAL  APPLICATIONS. 


291 


The  localizing  apparatus  designed  by  Sweet  consists  of  two  metal 
indicators,  one  pointing  to  the  centre  of  the  cornea  and  the  other  situated 
to  the  outer  canthus  at  a  known  distance  from  the  first.  Two  exposures 
are  made  in  order  to  give  different  relations  of  the  shadows  of  the  indi- 
cators and  of  the  body  in  the  eyeball,  one  with  the  X-ray  tube  horizontal 
or  nearly  so  with  the  plane  of  the  indicators,  and  the  other  with  the  tube 
below  this  plane. 

"  The  principle  of  the  method  may  be  understood  from  the  perspec- 
tive drawing  (Fig.  1G5).  Rays  coming  from  the  light  situated  at  A  cast 


FIG.  165.— Principles  of  the  method  of  localization.    (Courtesy  of  Dr.  Wm.  M.  Sweet.) 

shadows  of  two  ball-pointed  rods  and  an  object  in  the  eyeball,  and  give 
the  view  shown  on  the  surface  C.  In  this  instance  the  tube  is  in  front  of 
the  vertical  plane  of  the  two  indicators,  and  consequently  the  shadow  of 
the  centre  ball  will  be  throM'n  back  of  that  of  the  outer  ball.  When  the 
light  is  carried  below  the  plane  of  the  two  indicators,  the  shadows  of  the 
two  rods  are  formed  on  the  surface  D,  and  the  shadow  of  the  foreign 
body  in  the  eye  assumes  a  new  position.  If  the  distance  of  one  of  the 
indicating  rods  from  the  centre  of  the  cornea  is  known,  and  the  distance 


292 


ELECTRO-THERAPEUTICS. 


between  the  two  indicators  is  measured,  the  position  of  the  metal  in  the 
eye  may  be  determined,  since  the  shadow  of  the  foreign  body  preserves 
at  all  times  a  fixed  relation  to  the  shadows  of  the  indicating  balls,  in 
whatever  position  the  light  is  placed. 

"  Accurate  localization  requires  that  the  axis  of  the  eyeball  shall  be 
parallel  with  the  two  indicators  and  with  the  photographic  plate,  thai 
one  of  the  indicating  balls  be  opposite  to  the  centre  of  the  cornea  and  at 
a  known  distance  from  it,  and  that  both  indicators  are  at  a  measured 
distance  from  each  other.  The  plate-holder  and  indicators  have  been 
combined  into  a  special  apparatus  which  firmly  holds  the  head  of  the 
patient,  as  shown  in  Fig.  166.  The  arrangement  of  the  parts  of  this 


FIG.  166.— Indicating  apparatus  secured  to  the  side  of  the  head.    (Courtesy  of  Dr.  Wm.  M.  Sweet.) 

apparatus  is  such  that  the  indicators,  while  freely  adjustable,  are  always 
parallel  to  each  other  and  to  the  plate,  and  the  two  balls  are  perpen- 
dicular to  the  plate  and  15  cm.  distance  between  their  centres  when  the 
apparatus  is  in  place.  It  is  necessary  that  the  patient  rotate  the  eyeball 
to  bring  the  ocular  axis  parallel  with  the  plane  of  the  photographic 
plate,  and  that  the  operator  adjust  the  indicators  so  that  the  centre  ball 
is  opposite  the  centre  of  the  cornea. 

"To  determine  the  position  of  the  foreign  body  in  the  eye,  two 
circles  are  drawn,  representing  the  horizontal  and  vertical  sections  of  the 
normal  adult  eyeball,  and  upon  these  are  marked  the  situations  of  the 
indicating  balls  at  the  time  the  radiographs  are  made. 


THE  CLINICAL  APPLICATIONS. 


293 


FIG.  167.— Outline  drawing  of  a  radiograph,  made 
with  a  tube  slightly  above  the  plane  of  indicators.  A,  ball 
opposite  the  centre  of  the  cornea  ;  B,  ball  to  the  temporal 
side  ;  S,  foreign  body.  (Two-thirds  normal  size.) 


"Lines  are  drawn  through  the  shadow  of  each  of  the  indicating 
balls  on  the  two  radiographs.  On  the  negative  made  with  the  tube  hori- 
zontal and  parallel  with  the  plane  of  the  indicators,  a  measurement  is 
made  of  the  distance  the  shadow  of  the  metallic  body  is  above  or  below 
the  shadow  of  each  of  the  in- 
dicators. This  distance  is 
entered  above  or  below  the 
spots  representing  the  two 
indicators  on  the  diagram  of 
the  vertical  section  of  the  eye- 
ball. Thus,  in  the  radiograph 
(Fig.  167)  the  distance  of 
the  foreign  body  (8)  below 
each  of  the  indicators  (O  S 
and  X  S)  is  entered  below 
the  spots  A  and  B,  front 
view,  Fig.  169.  A  line  drawn 
through  the  points  C  and  D 
gives  the  direction  of  the 
X-rays  at  the  time  the 

shadow  of  the  foreign  body  was  cast  upon  the  plate.  Similar  measure- 
ments of  the  distance  that  the  shadow  of  the  foreign  body  is  below 
the  shadow  of  each  of  the  indicators  are  made  on  the  second  negative 
(Fig.  168),  and  these  are  likewise  entered  below  the  points  A  and  B,  rep- 
resenting the  two  balls  on  the  vertical  section  of  the  eyeball.  These 

measurements  are  A  F  and 
BE.  A  line  drawn  through 
the  points  E  and  F  gives 
the  direction  of  the  rays 
when  the  second  negative 
was  made.  Since  these  two 
lines  indicate  the  plane  of 
the  shadow  of  the  foreign 
body  at  each  exposure,  the 
intersection  of  the  lines 
must  be  the  location  of  the 
metal  in  the  eye,  as  meas- 
ured above  or  below  the 
horizontal  plane  of  the 
globe  and  to  the  temporal 
or  nasal  side.  To  deter- 
mine the  distance  of  the  foreign  body  back  of  the  centre  of  the  cornea,  the 
negative  made  with  the  tube  horizontal  is  taken,  and  the  distance  is 
measured  that  the  shadow  of  the  ball  opposite  the  centre  of  the  cornea 
lies  posterior  to  that  of  the  external  ball.  This  distance  is  entered  directly 


FIG.  1GS.— Outline  drawing  of  radiograph,  tube  below 
the  plane  of  indicators.  A,  ball  below  centre  of  the  cornea ; 
B,  external  ball ;  .S',  foreign  body.  (Two-thirds  normal  size.) 


294 


ELECTRO-THERAPEUTICS. 


above  the  external  ball  ou  the  diagram  representing  the  horizontal 
section  of  the  eyeball.  A  line  drawn  from  K  through  the  centre 
ball  gives  the  direction  of  the  rays  at  the  time  the  radiograph  was 
made.  On  the  same  negative  is  measured  the  distance  that  the  shadow 
of  the  foreign  body  is  back  of  the  shadow  of  each  of  the  indicators,  and 
these  distances,  B  J  and  A  H,  are  entered  on  the  diagram.  A  line  is 
drawn  through  the  points  J  and  H,  and  since  this  line  represents  the 
plane  of  the  shadow  of  the  foreign  body,  the  point  at  which  a  perpen- 
dicular drawn  from  the  situation  of  metal  as  shown  on  the  vertical  sec- 
tion of  the  eyeball  intersects  this  line  indicates  the  situation  of  the  body 

Size  of  body by by mm. 

Situation 

miaback  of  center  of  cornea, 
mmbelow  horizontal  plane . 

mm.to side  of 

vertical  plane. 


Honzontat 
section. 


Side  view 


Front  view 


Front  view. 


-  D 


Side  view 


Fio.  169.— Dr.  William  M.  Sweet's  chart  for  plotting  location  of  foreign  bodies  in  the  eye. 
I  Two-thirds  normal  size. ) 

back  of  the  centre  of  the  cornea.  If  the  position  of  the  tube  from  the  eye 
has  been  measured,  its  distance  is  indicated  on  the  line  drawn  from  K 
through  the  centre  ball  A.  A  line  through  J  to  this  point  indicates  the 
divergence  of  the  rays.  This  means  of  determining  the  position  of  the 
plane  of  shadow  of  the  foreign  body  is  more  accurate  than  when  the 
measurement  is  made  of  the  shadow  of  the  body  above  each  of  the  balls, 
and  should  be  followed,  especially  if  the  body  is  some  distance  away  from 
the  anterior  segment  of  the  globe  or  is  in  the  orbit. 

"If  the  foreign  body  has  passed  into  the  orbit,  the  rotation  of  the 
eyeball  to  insure  parallelism  of  the  ocular  axis  wit h  the  plane  of  the 
plate  leads  to  a  slight  error  in  the  determination  of  the  position  of  the 


THE  CLINICAL  APPLICATIONS.  295 

metal.  To  eliminate  this  error  necessitates  a  knowledge  of  the  angle  of 
the  orbit  with  the  plate  or,  its  equivalent,  the  amount  of  deviation  of 
the  eyeball  from  the  primary  position,  and  the  consideration  of  this 
angle  in  plotting  the  diagrammatic  circles  representing  the  eyeball. 

"  The  indicating  apparatus  is  secured  to  the  side  of  the  head  corre- 
sponding to  the  injured  eye,  and  the  tube  placed  about  12  or  15  inches 
(30  or  38  cm.)  to  the  opposite  side  and  slightly  forward.  The  patient  is 
in  the  recumbent  posture,  to  insure  steadiness  of  the  head.  After  the 


FIG.  170.— Mackenzie  Davidson's  localizer. 


indicating  rods  have  been  adjusted,  the  patient  fixes  an  object  about  5  to 
10  feet  distant,  so  placed  that  the  visual  axis  of  the  injured  eye  shall  be 
parallel  to  the  photographic  plate.  An  exposure  of  from  10  to  20 
seconds  will  clearly  outline  the  bones  of  the  orbit,  and  secure  a  shadow 
of  any  body  opaque  to  the  rays  in  the  eyeball  or  in  its  neighborhood." 

Another  method  of  equal  accuracy  was  introduced  by  Mackenzie 
Davidson,  who  published-  a  description  of  it  in  the  British  Medical 
Journal,  January  1,  1896. 

Davidson's  Method.  (Fig.  170.)— The  theory  of  this  method  briefly  is 
as  follows  : l  "  The  Crookes  tube  is  placed  in  a  holder,  which  can  slide 
horizontally.  A  perpendicular  is  dropped  from  the  point  in  the  anode  of 

1  The  Archives  of  the  Runtgen  Ray,  May,  1898. 


296  ELECTKO-THERAPEUTICS. 

the  tube  where  the  X-rays  originate  on  the  point  where  two  wires  cross 
each  other  at  right  angles,  and  one  of  the  wires  must  be  parallel  to  the 
horizontal  bar  along  which  the  tube-holder  slides ;  so  that,  when  the  tul>e 
is  displaced  along  the  bar,  a  perpendicular  dropped  from  the  X-ray  point 
in  the  anode  would  always  fall  upon  this  wire.  The  wires  in  reality  rep- 
resent two  planes  at  right  angles  to  each  other,  and  the  photographic  plate 
representing  the  third  plane.  Eventually  I  obtain  the  three  planes 
which  are  at  right  angles  to  each  other,  and  whose  relation  to  the  part 
of  the  patient's  body  skiagraphed  is  known. 

"For  practical  purposes  it  is  convenient  to  have  the  wires  stretched 
across  a  flat  board  or  sheet  of  vulcanite,  and  this  can  be  placed  on  a  table 
in  the  correct  position  below  the  horizontal  bar,  and  fixed  to  the  table  by 
means  of  drawing  pins.  The  wires  being  inked  so  as  to  mark  the  skin,  a 
photographic  plate,  enclosed  in  black  paper  in  the  usual  way,  is  placed 
beneath  the  cross  wires.  The  perpendicular  distance  from  the  anode  to 
where  the  wires  cross  each  other  is  carefully  measured  and  noted. 

"  It  is  now  necessary  to  decide  at  what  distance  apart  the  tube  is  to  be 
displaced  in  order  to  take  the  two  skiagrams.  It  does  not  matter  greatly, 
2J,  5  or  more  inches  (6  to  12  cm.  etc.)  of  displacement  may  be  given. 
Having  decided  this  point,  movable  clips  are  so  placed  as  to  limit  the 
sliding  of  the  tube-holder  to  the  required  extent.  The  tube  is  then  dis- 
placed to  one  side,  and  the  patient  places  the  part  to  be  photographed  on 
the  cross  wires,  being  careful  not  to  move,  once  the  skin  has  come  in 
contact  with  the  wires;  because  it  is  of  the  utmost  importance  that  the 
shadow  of  the  cross-wires  on  the  negative  should  be  in  register  with  the 
ink  mark  left  on  the  patient's  skin.  Further  it  is  convenient  to  put  a 
small  coin  on  one  corner  of  the  plate,  and  also  mark  the  patient's  skin 
nearest  to  it.  This  reveals  to  the  operator  the  relation  of  the  plate  to 
the  skin. 

"One  exposure  is  made,  and  the  tube  is  then  displaced.  A  second 
exposure  is  given,  preferably  on  the  same  plate,  provided  a  suitable 
apparatus  be  used  to  enable  the  plates,  if  a  different  plate  be  used,  to  be 
changed  without  disturbing  the  position  of  the  parts  at  all. 

"Having  developed  and  fixed  the  negative,  it  will  show  a  single 
shadow  of  the  cross- wires,  but  two  shadows  of  the  foreign  body.  In 
order  to  interpret  this  correctly,  I  devised  the  following  apparatus,  which 
may  be  called  the  '  cross-thread  localizer ' : 

"A  sheet  of  plate  glass  is  fixed  horizontally,  having  two  lines 
marked  upon  its  surface,  crossing  at  right  angles  in  the  centre.  A 
mirror  hinged  below  it  allows  the  light  to  be' reflected  from  below,  so  as 
to  render  details  on  the  negative  visible  by  ordinary  light. 

"A  scale  fastened  to  a  horizontal  bar  slides  up  and  down  on  two 
rods  which  support  its  ends.  The  scale  has  small  notches  opposite  its 
marks.  This  is  so  placed  that  a  perpendicular  dropped  from  the  O°  or 
middle  point  of  the  scale  falls  exactly  where  the  lines  cross  on  the  glass 


THE  CLINICAL  APPLICATIONS.  297 

stage.  Furthermore,  the  edge  of  the  scale  is  parallel  to  the  line  running 
right  and  left  on  the  glass.  The  negative  is  now  placed  upon  this  glass 
stage,  the  operator  being  careful  to  bring  the  shadow  of  the  cross-wires 
into  register  with  the  cross  on  the  stage,  placed  with  its  marked  quadrant 
in  correct  position.  The  gelatine  surface  can  be  protected  by  a  thin 
transparent  sheet  of  celluloid. 

1 '  The  scale  is  now  raised  or  lowered  so  as  to  bring  the  O°  precisely 
the  same  distance  above  the  negative  as  was  the  anode  of  the  Crookes 
tube  when  the  negative  was  produced.  All  that  is  now  necessary  is 
to  place  a  fine  silk  thread  through  the  notch  on  one  side  of  the  O°  on 
the  scale,  and  another  thread  through  a  notch  on  the  other  side,  at 
exactly  the  same  distance  as  that  which  measured  the  displacement  of 
the  X-ray  tube. 

"Small  weights  are  attached  to  the  ends  of  the  two  threads  to  keep 
them  taut,  while  the  other  ends  are  threaded  into  fine  needles  fastened  to 
pieces  of  lead.  Thus  the  needle  with  the  thread  can  be  placed  upon  any 
point  of  the  negative  and  remain  in  position.  In  short,  the  negative  is 
now  relative  to  the  cross-lines,  the  scale,  and  the  notches  from  which  the 
two  threads  come,  exactly  the  same  as  it  was  to  the  cross-wires  and 
Crookes  tube  when  being  produced. 

k' A  needle  with  the  thread  is  placed  upon  any  point  on  one  of  the 
shadows  of  the  foreign  body,  and  the  other  needle  is  placed  upon  a 
corresponding  point  in  the  other  shadow,  and  it  will  be  found  that  the 
threads  cross  each  other,  just  touching  and  no  more.  The  point  where 
they  cross  represents  the  position  of  the  foreign  body.  A  perpendicular 
can  be  dropped  from  this  point  to  the  negative  below,  and  a  mark  made 
at  the  point  where  it  touches  the  negative.  Then  with  a  pair  of 
compasses,  the  distance  of  this  point  from  the  two  cross-wires  can  be 
measured. 

"The  height  of  the  plate  where  the  threads  cross  gives  one  co- 
ordinate, that  is  the  depth  of  the  foreign  body  below  the  skin,  which 
rested  on  the  photographic  plate.  The  other  two  measurements  give  the 
other  two  co-ordinates. 

11  As  the  mark  of  the  wires  is  left  on  the  patient's  skin,  all  that  is 
required  is  to  measure  the  two  co-ordinates  on  the  skin  that  give  the 
point  below  which  the  foreign  body  will  be  found  at  the  depth  given  by 
the  third  co-ordinate.'' 

GroxsiiHtn'x  Method  of  Localizing  a  Foreign  Body  in  Eye. — Karl  Gross- 
man,1 in  localizing  a  foreign  body  in  the  eye,  utilized  the  eye  itself  for 
the  purpose  of  obtaining  the  necessary  parallax  of  the  shadow ;  the 
vacuum  tube,  the  head  of  the  patient,  and  the  photographic  plate  retain 
their  relative  positions  to  one  another  unchanged.  He  describes  this 
method  as  follows:  u Either  one  or  two  pairs  of  skiagrams  are  taken. 

1  Liverpool  Medico-Chir.  Journal,  January,  1899,  pp.  359-361. 


298  ELECTRO-THERAPEUTICS. 

The  first  pair  is  obtained  by  making  the  patient  look  (a)  downward,  (6) 
upward,  ill  the  same  plane,  the  X-rays  coming  from  the  other  side  of  the 
face  and  somewhat  in  front  of  it.  If  the  foreign  body  be  in  the  eyeball, 
the  shadow  has  moved  from  (a)  to  (6)  as  follows :  upward  if  in  the 
anterior  half-hemisphere,  downward  if  in  the  posterior  half-hemisphere, 
forward  if  in  the  inferior  half- hemisphere,  backward  if  in  the  superior 
half-hemisphere  ;  the  axis  of  these  four  half-hemispheres  being  at  the 
same  time  the  axis  of  rotation  for  the  upward  movement. 

"If  the  shadow  has  not  moved,  the  foreign  body  might  still  be  in  the 
eyeball, — viz.,  at  any  point  on  the  axis  of  rotation.  In  this  case  the  second 
pair  of  skiagrams  would  become  necessary,  the  patient  this  time  having 
to  look  at  a  point  (c)  teniporalward,  (<Z)  nasalward,  in  the  horizontal 
plane.  A  movement  of  the  shadow  from  (c)  to  (J)  would  mean  the 
presence  of  a  foreign  body  in  the  eye, — viz.,  in  the  temporal  hemisphere 
if  forward  ;  in  the  nasal  hemisphere  if  backward.  The  relative  position 
of  the  tube,  head,  and  plate  need  only  remain  the  same  for  the  two  r\- 
posures  of  each  pair, — viz.,  for  (a)  and  (6)  on  the  one  hand,  and  for  (c) 
and  (<Z)  on  the  other, — but  may  be  a  different  one  for  each." 

Fox's1  Method  of  Localization.  (Fig.  171.) — Briefly  this  method  con- 
sists first  of  cocainizing  the  eye  and  in  the  introduction,  beneath  the 
lids,  of  an  appliance  called  a  "conformer."  This  device  consists  of 
an  elliptical  wire  of  gold,  divided  by  cross-wires  of  gold  (concaved 
on  one  side  so  as  to  slip  over  and  fit  the  anterior  surface  of  the  eyeball) 
running  in  opposite  axes,  dividing  the  eyeball  into  quadrants,  anteriorly. 
The  next  step  in  this  method  consists  in  skiagraphing  the  eye  in  two 
directions,  so  as  to  get  good  imprints  on  the  sensitive  plate  of  both  the 
foreign  body  and  the  conformer.  Thus,  we  produce  a  skiagram  in  the 
anterior  diameter,  placing  a  small  sensitive  i>late  in  front  and  against  the 
eyeball,  and  the  tube  in  back  of  the  head,  with  the  target  pointing  in  the 
direction  of  the  eyeball.  The  tube  should  be  distant  from  the  sensitive 
plate  22  to  30  inches  (55  to  75  cm.).  The  time  of  exposure  is  from  1* 
to  2J  minutes,  depending,  of  course,  upon  the  thickness  (or  rather  the 
antero- posterior  diameter)  of  the  head  examined.  With  a  properly 
exposed  plate  and  a  correctly  developed  negative,  there  will  result  a 
picture  showing  the  relation  the  foreign  body  bears  to  the  dividers  of  the 
conformer.  A  second  skiagram  is  produced  by  placing  the  sensitive 
plate  against  the  temple  corresponding  to  the  side  that  is  to  be  examined, 
and  the  tube  on  the  opposite  side,  with  the  target  pointing  in  direct  line 
with  the  temples.  The  tube  should  be  from  20  to  30  inches  (50  to  75  cm.) 
distant  from  the  sensitive  plate.  The  time  of  exposure  should  be  from  1 
to  1|  minutes,  depending  upon  the  thickness  of  the  head  in  this  diameter. 
This  skiagram  shows  the  depth  of  the  foreign  body,  measured  from  the 
peak  or  base  of  the  conformer. 

1  Philadelphia  Medical  Journal,  February  1,  1902,  pp.  213-220. 


K.B. 


FIG.  171.— Fox's  LOCALTZER.— Bullet  in  the  orbit:  5 >-,  shot.  The  wire  over  the  cornea  illus- 
trates Fox's  method  of  localization.  1,  frontal  sinus ;  2,  thickness  of  frontal  bone  ;  3,  the  zygoma ;  JV.J?., 
nasal  bone. 


- 


THE  CLINICAL  APPLICATIONS. 


This  method  is  entirely  different  from  any  of  the  others,  and,  unless 
great  care  is  exercised  in  securing  the  exposures  at  right  angles  to  each 
other,  the  chance  for  error  in  localization  is  great.  Prior  to  this  method 
I  placed  the  couformer  over  the  closed  eyelids. 


E.  VARIOUS  METHODS  OF  LOCATING  FOREIGK  BODIES. 

Screen  Method. — This  was  the  first  method  employed.  In  order  to 
attain  the  best  results,  the  examiner  should  have  had  thorough  experience 
in  this  line  of  work.  The  fluoroscope  should  first  be  used,  to  demonstrate 
the  presence  of  the  foreign  body.  The  hood  is  next  removed  from  the 
screen,  and  the  latter  used  sep- 
arately, in  the  same  position  as 
when  first  located.  A  mark, 
made  by  an  indelible  pencil,  is 
placed  on  the  part  directly  over 
the  spot  where  the  shadow  of 
the  foreign  body  presents  itself, 
this  mark  being  directly  behind 
the  screen. 

A  second  mark  is  made  on 
the  opposite  side  of  the  member 
corresponding  to  the  area  of  the 
foreign  body.  These  marks,  ly- 
ing in  an  even  plane,  should  be 
both  marked  "1"  and  "  1." 
The  depth  of  tissue  in  which  the 
bullet  lies  is  next  ascertained  by  moving  the  screen  slightly  up  and 
down  ;  if  the  shadow  of  the  foreign  body  moves  considerably,  it  indi- 
cates that  the  foreign  object  is  deeply  imbedded.  On  the  contrary, 
if  the  shadow  moves  but  slightly,  it  indicates  that  the  object  is  superfi- 
cially imbedded.  The  next  step  consists  in  viewing  the  foreign  body  at 
exactly  right  angles  to  the  first  position  ;  to  do  this  the  part  under  exami- 
nation, and  not  the  tube,  should  be  turned.  The  skin  of  the  part  should 
be  marked  over  the  area  of  the  shadow  at  both  sides  by  the  figures  "2," 
ii2.">  Next  in  order  draw  lines  from  2-2  and  1-1,  and  the  point  of 
intersection  corresponds  to  the  exact  location  of  the  foreign  object.  For 
marking  the  skin,  .some  prefer  diluted  silver  nitrate  crayons,  but,  as 
they  are  more  or  less  irritating,  I  employ  indelible  pencils.  Fig.  172 
illustrates  a  simple  method  of  localization. 

Punctograpli. — This  consists  of  a  stout  brass  ring  securely  mounted  to 
a  handle  of  ebonite.  A  pencil  of  aniline  is  attached  to  the  base  of  the 
handle.  The  pencil  is  controlled  by  a  check  spring,  and  when  the  latter 
is  pressed,  the  pencil  is  released,  which  now  jumps  through  the  centre  of 
the  brass  ring,  marking  the  skin  at  the  point  where  the  shadow  presented 


FIG.  172. — THE  RIGHT-ANGLE  METHOD  OF  LO- 
CALIZATION.— P,  photographic  plate;  T1,  position  of 
the  tube;  T2,  position  of  the  tube  at  right  angles  to 
the  above;  F.A,  foreign  body. 


300  ELECTRO-THERAPEUTICS. 

itself,  as  seen  through  the  screen.  In  localizing  a  foreign  body  by  this 
method,  two  of  these  instruments  are  simultaneously  employed.  The 
screen  should  be  clamped  to  a  frame,  thus  allowing  the  hands  perfect 
freedom  for  manipulating  the  two  instruments. 

In  examining  the  forearm  for  a  foreign  body,  let  us  say  a  bullet,  the 
part  is  brought  between  the  screen  and  the  tube,  and  the  shadow  revealed. 

The  first  punctograph  is  then  placed  so  that  the  opening  of  the  brass 
ring  encircles  the  shadow  cast  by  the  bullet.  A  second  punctograph  is 
applied  similarly  and  directly  opposite  the  first.  The  springs  of  both 
punctographs  are  now  simultaneously  released,  and  there  result  marks 
on  the  skin  at  opposite  ends  of  a  line.  The  arm  is  next  rotated  through 
the  quadrant  of  a  circle,  the  punctographs  again  being  applied,  and  the 
springs  released  as  in  the  beginning.  It  must  thus  become  self-evident 
that  four  marks  are  now  upon  the  arm,  and  by  ordinary  calculation  and 
measurement  the  position  of  the  bullet  may  be  easily  determined. 

Reiny*8  Method. — The  Remy  localizer,  which  is  an  extremely  compli- 
cated device,  and  is  with  greatest  difficulty  elucidated  by  the  use  of  dia- 
grams, is  thus  briefly  reviewed  by  A.  \V.  Isenthal,  F.R.P.S.,  and  H.  Snow- 
den  Ward,  F.R.P.S.,  members  of  the  Council  of  the  Routgen  Society.1 

"The  Reiny  localizer  is  a  complicated  apparatus,  founded  on  the 
principle  that  it  is  necessary  to  'materialize'  those  two  X-rays  which 
connect  the  anode  with  the  foreign  body  and  its  screen  shadow  for  two 
positions  of  the  tube.  By  means  of  suitably  placed  sights  and  stops,  one 
is  enabled  to  bring  the  pointed  rods  (representing  the  X-rays)  always 
back  to  their  proper  plane,  so  that  the  latter  and  the  depth  of  the 
foreign  object  may  be  marked  on  the  patient."  2 

Barrel's  Method. — Frank  R.  Barrel,  M.A.,  B.Sc.,of  the  University 
College,  Bristol,  England,  thus  tersely  describes  his  localizer. 

"  My  method  requires  no  plumb-line,  no  threads,  and  no  levelling. 
My  'apparatus'  consists  of  two  metal  cylinders  whose  ends  have  been 
carefully  turned  perpendicular  to  their  axis.  A  convenient  size  is  four 
inches  long  and  one  inch  in  diameter.  Place  these  cylinders  upright  on 
the  plate  during  an  exposure,  and  close  to  the  limb  holding  the  foreign 
body.  The  shadows  thrown  indicate  the  focus  position  of  the  tubes.  To 
secure  good  long  shadows,  place  the  cylinders  near  the  end  of  the  plate 
furthest  from  the  tube.  After  the  first  excitation  shift  the  tube  six  or 
ten  inches,  the  cylinders  are  also  shifted  towards  the  opposite  end  of  the 
plate,  and  then  the  tube  is  again  excited,  giving  rise  to  the  second  set  of 
shadows  from  the  foreign  bodies  and  the  cylinders.  Lines  are  ruled 
along  the  edges  of  the  two  corresponding  cylinder  shadows  for  one  tube 
position,  and,  producing  them  till  they  meet,  we  obtain  that  point  on  the 

'Practical  Radiography,  Dawbarn  and  Ward,  Publishers,  1901. 
2  For  a  comprehensive  description  of  the  apparatus  and  its  mode  of  application, 
the  reader  is  referred  to  Archives  of  the  Rontgen  Ray,  August,  1900. 
8  Archives  of  the  Rontgen  Ray,  May,  1900. 


THE  CLINICAL  APPLICATIONS:  301 

plate  which  was  vertically  beneath  the  tul>e  focus  during  the  correspond- 
ing exposure.  Connecting  the  two  points  thus  found  with  the  corre- 
sponding shadows  of  the  foreign  body,  we  obtain  two  lines  which  intersect 
in  a  point  which  is  vertically  below  the  actual  foreign  body." 

S/x-ittott'x  MrtlHxl.1 — For  such  cases  as  needles  or  bullets  in  the  hand, 
arm,  or  leg, — /.  e.,  in  parts  easily  manipulated, — no  special  apparatus  is 
required  and  no  photographic  process  involved.  Shenton  describes  his 
method  as  follows  :  "Hold  the  part,  for  example,  a  hand  containing  a 
needle,  before  the  fluorescent  screen.  Start  with  the  screen  and  the 
anode  of  the  tube  as  nearly  parallel  as  possible.  When  needle  and  bones 
are  distinctly  seen,  sway  the  screen  and  hand  from  side  to  side,  and  note 
the  change  in  relation  of  bones  and  needles.  It  is  evident  that  the  image 
of  whichever  is  furthest  from  you  and  from  the  surface  of  the  screen 
will  move  the  faster.  If  the  needle  moves  across  the  bones,  its  position  is 
deeper  than  the  bone  ;  if  bones  move  across  needle,  the  latter's  position 
must  be  between  the  surface  of  the  screen  and  the  bone.  Should  the 
needle  appear  to  remain  stationary,  place  a  pointer  against  this  image  on 
the  screen,  and  ascertain  whether  it  moved  a  little  or  not  at  all.  Verify 
these  results  by  reversing  the  hand  and  repeating  the  manoeuvres.  A 
little  practice  enables  one  to  give  as  near  an  estimate  of  the  needle's  real 
depth  as  any  surgeon  could  require,  and  such  suggestions  as  'just  beneath 
the  palm,'  'midway  between  bones  and  skin,'  'lower  end  between  the 
bones,'  'upper  one-eighth  of  an  inch  between  the  skin  of  the  back  of 
the  hand,'  are,  in  my  experience,  sufficient  for  any  operator.  I  doubt 
if  a  calculation  in  millimetres  would  be  of  more  use.  The  body  is  an 
awkward  thing  to  apply  the  millimetre  scale  to,  and  a  little  pressure  on 
the  skin,  or  a  little  swelling  beneath  it,  will  overthrow  such  minute 
calculations.  The  needle's  depth  being  ascertained,  it  only  remains  to 
find  its  position  in  the  horizontal  planes,  a  task  which  presents  few 
difficulties. 

••  When  found,  this  position  should  be  marked  upon  the  skin.  The 
advantages  of  this  method  are  its  rapidity  of  performance,  the  process 
taking  but  a  few  seconds,  and  the  economy  of  material,  both  photo- 
graphic and  electrical.  For  localization  in  other  parts  of  the  body,  and 
for  photographically  recording  results,  I  have  constructed  an  instrument 
which  in  principle  is  the  same  as  the  method  just  described,  save  that  the 
tube  is  swayed,  while  the  part  viewed  is  held  in  position  by  bauds  and 
tension  springs.  The  tube  is  moved  by  the  observer  from  his  side  of  the 
screen,  the  distance  it  travels  being  regulated  by  sliding  steps.  A  fine 
vertical  wire  is  stretched  in  the  centre  of,  and  in  contact  with,  the  screen. 
The  image  of  the  foreign  body  is  to  correspond  with  this  line  when  the 
tube  is  in  the  mid-position.  Upon  moving  the  tube  from  the  extreme 
right  to  the  extreme  left,  the  image  of  the  foreign  body  on  the  screen  is 

1  Archives  of  the  R.'mtpen  Ray,  August,  1899. 


:;OL>  ELECTRO-THERAPEUTICS. 

seen  to  pass  from  left  to  right.  Its  relative  rate  of  travelling,  compared 
with  the  same  portion  of  bone,  is  noted  as  before.  For  accurate  measure- 
ments the  true  position  assumed  by  the  foreign  body  is  marked  by 
pencil  on  a  celluloid  film  in  contact  with  the  screen.  This  measurement 
being  secured,  the  distance  the  tube  travels,  and  the  distance  from  the 
mid-point  of  the  line  adjoining  the  two  extreme  positions  of  the  tube, 
must  be  ascertained.  A  simple  rule  of  three  will  now  give  the  distance 
of  the  object  sought  from  the  screen." 

Harrison'*  Mrthod.1 — "A  seven-inch  square  is  drawn  on  a  board  and 
its  centre  is  accurately  marked  ;  at  the  ends  of  a  line  drawn  through  the 
centre,  perpendicular  to  two  of  the  sides,  two  upright  rods  are  fixed  (for 
convenience  of  carriage,  these  can  be  made  to  take  in  and  out)  ;  at  a 
height  of  seven  inches  on  each  of  these  pillars,  a  hook  or  loop  is  placed. 
Take  the  case  of  a  needle  in  the  hand.  A  double  photograph  of  the 
needle  and  hand  is  taken  with  the  light  alternately  right  and  left.  A 
tracing  of  this  photograph  is  then  taken  on  the  sensitive  side,  marking 
distinctly  on  the  ends  of  the  needle.  The  tracing  is  then  placed  so  that 
its  centre  coincides  with  the  centre  of  the  square.  Pins  are  then  stuck, 
slantingly  through  the  tracing,  into  the  board  at  the  ends  of  the  needle. 
Cross  threads  are  carried  from  the  pins  to  the  loops  and  kept  stretched 
by  small  weights.  Where  these  threads  intersect  will  show  the  position 
of  the  needle  relatively  to  the  sensitive  plate,  which  is  represented  by 
the  tracing." 

Double  Focus  Tube  Localization. — This  method  was  devised  by  Leon- 
ard 2  and  is  as  follows  :  The  technic  required  for  triangulation  methods 
prevented  their  general  employment,  and  to  simplify  the  application  of 
the  same  principles,  Leonard  has  had  made  a  tube  with  two  cathodes  and 
two  anodes,  and  hence  two  sources  of  rectilinear  rays.  This  avoids  errors 
when  the  position  of  the  tube  has  to  be  changed  or  separate  plates  used, 
and  it  has  made  rapid  accurate  localization  with  the  fluoroscope  easy. 
The  fluoroscopic  method  is  as  follows :  Fix  the  screen  in  a  perpendicular 
position.  Place  the  tube  horizontally  so  that  the  mid-point  of  the  line 
connecting  the  two  sources  of  rays  is  perpendicular  to  the  plane  of  the 
screen,  and  at  a  known  distance  from  the  centre  of  the  screen  marked  by 
an  opaque  cross.  Place  the  limb  before  the  screen  so  that  the  two  shadows 
of  the  foreign  body  will  fall  equally  distant  on  each  side  of  the  opaque 
spot  and  on  the  same  line.  Mark  the  spot  in  the  patient's  skin  with 
nitrate  of  silver.  By  placing  an  opaque  rod  on  the  other  side  of  the  limb, 
where  its  shadows  are  equidistant  from  the  opaque  spot,  the  perpendicu- 
lar is  found  and  marked  on  that  side.  The  foreign  body,  therefore,  lies 
on  this  line  at  a  distance  from  the  opaque  spot,  that  is  determined  by 
measuring  the  distance  between  the  two  shadows  with  calipers  and 

1  British  Medical  Journal,  April  2,  1898. 
'American  X-ray  Jour.,  November,  1899. 


THE  CLINICAL  APPLICATIONS.  303 

plotting  the  shadowy  paths  by  the  graphic  process,  as  when  plates  are 
employed,  or  by  the  cross-thread  method. 

Stereoscopic  Method.  —  This  method  has  already  been  discussed.  I 
employ  it,  as  it  has  yielded  satisfactory  results. 

THanffvfation  Method  of  Localizing  Foreign  Bodies  with  Measurement 
on  a  Graduated  "  T"  Scale.  (Figs.  173,  174.)— In  order  to  find  the  depth 
of  the  foreign  body  on  the  scale,  bring  the  lower  bar  to  the  figure  10  on 
the  upright.  Connect  a  line  at  20  on  the  uppermost  horizontal  bar,  inter- 
secting at  1.6  [DE]  on  the  middle  horizontal  bar,  which  registers  4.53cm. 
011  the  vertical  bar,  as  shown  in  the  following  formula  : 

A  =  Position  of  the  tube  in  the  first  exposure. 
B  =  Position  of  the  tube  in  the  second  exposure. 
AB  =  Distance  of  the  displacement. 
C  =  Foreign  body. 

D  —  Shadow  of  the  foreign  body  on  the  plate  (first  exposure). 
E  =  Shadow  of  the  foreign  body  on  the  plate  (second  exposure). 
CA  =  50  cm.  —  CD. 

There  are  two  triangles,  =  CAB  and  CDE. 
DE  =  1.6  cm.,  which  is  known. 
AB  =  20  cm. 

CD  _  CA     20  CD  =  2(50  cm.  —  CD) 
2        -    20      20  CD  =  (100  cm.  —  2CD) 
20  CD  +         2  CD  =  100  cm. 
22  CD  =  100  cm. 

100 
CD  =  -  —  =  4.53,  distance  of  the  foreign  body. 

SMB 

Orlhodiagraphic  Localizer  of  Grashey. — Frequently  it  is  found  that 
foreign  bodies  imbedded  in  the  tissues  cannot  be  located  with  exactness, 
even  when  felt  beneath  the  skin,  or  when  Rontgen  photographs  are  taken 
in  different  projections,  because  of  the  possibility  of  the  foreign  body 
varying  its  position  to  the  bony  parts  from  minute  to  minute.  If  the 
hand  during  the  operation  is  not  kept  in  exactly  the  same  position  as 
during  the  taking  of  the  photograph,  then  the  projection  will  be  wrong. 
Recently  Dr.  R.  Grashey,  of  Munich,  devised  an  orthodiagraphic 
localizer.  (Fig.  175.) 

The  operator  sits  before  the  table  and  is  looking  with  one  eye  into 
the  tube,  and  he  sees  an  illuminated  picture  in  the  mirror  of  the  crysto- 
scope.  With  the  other  eye  (the  room  not  being  darkened)  he  can  look 
directly  at  the  wound.  The  current  is  interrupted  and  closed  by  the  help 
of  a  pedal.  The  tube  is  enclosed  in  a  box,  containing  below  a  diaphragm, 
capable  of  effecting  so  small  an  opening  that  only  a  limited  field  of  opera- 
tion is  illuminated.  In  this  way,  and  by  a  plate  of  lead  glass  inserted  in 
the  front  wall  of  the  box,  the  operator  is  protected.  The  box  is  fixed  on 
a  support  connected  with  one  leg  of  the  table,  and  revolves  horizontally. 
Thus,  it  can  be  turned  aside  with  a  sterilized  cloth,  and  when  its  use  is 


304 


ELECTKO-THEBAPEUTIC8. 


again  required  it  can  be  turned  back,  and  it  will  be  at  once  over  the 
former  position,  above  the  fl Horoscope.  The  forearms  of  the  operator  rest 
comfortably  on  movable  supports.  N 

The  illustration  (Fig.  176)  shows  the  path  of  the  rays  emanating 
from  the  anode  of  the  tube  K.  that  is  in  the  box  BK.  Through  the  open- 
ing B,  in  the  diaphragm,  we  see  the  body  K,  containing  the  foreign  body 


FIG.  173.— "T"  scale  used  in  triangulation  method.     FIG.  174.— Scheme  of  application  of  the  "T"  scale. 

F.  Upon  the  fluoroscope  L,  inserted  on  the  table  O,  this  picture  is  ob- 
liquely reflected  by  the  mirror  S,  in  the  dark  chamber  D,  into  the  tele- 
scopic tube  T.  In  that  case  the  anode  focus  and  the  centre  of  the  fluo- 
roscope M,  marked  by  a  little  shot  pasted  on  it,  lie  vertically  one  below 
the  other.  Thus  it  becomes  easy  to  adjust  any  other  body  orthodiagraph- 
ically  in  line  with  the  normal  ray,  as,  for  instance,  the  foreign  body  F 
contained  in  the  hand  K.  If  you  move  the  point  of  a  knife  into  the 
illuminated  picture  until  its  shadow  covers  that  of  the  shot  and  also 
the  foreign  body  that  has  previously  been  adjusted,  then  the  point  of  the 
blade  must  be  exactly  above  that  of  the  foreign  body. 


THE  CLINICAL  APPLICATIONS. 


For  the  determination  of  the  location  of  a  foreign  body,  whether 
in  the  eyeball  or  orbital  cavity,  take  two  separate  skiagraphs,  with  the 


FIG.  175. — Orthodiagrapliic  localizer  of  Grashey. 


t    IP 


FIG.  176.— Diagrammatic  view  of  the  same. 

tube-holder  and  plate  in  the  same  position  in  both  instances ;  or  during 
half  the  exposure  the  patient  rolls  the  eyeball ;  if  the  shadow  of  the 
foreign  body  appears  double,  the  offending  substance  is  in  the  eyeball ;  if 
in  the  orbital  cavity,  the  shadow  will  be  single. 
to 


CHAPTER   IV 

APPLICATION  OF  THE  X-EAYS  IN  DISEASES  OF  THE 
THOEACIC  OEGANS. 

THIS  is  subdivided  into  the  respiratory  and  circulatory  systems. 

The  value  of  the  X-ray  as  a  diagnostic  agent  in  thoracic  examinations 
has  been  and  is  being  constantly  demonstrated.  The  thorax  and  its 
contained  viscera  are  easy  of  examination  both  by  the  fluoroscope  and 
skiagram,  largely  due  to  the  circumstance  that  the  lungs  are  transparent 
to  the  rays.  By  a  fluoroscopic  examination  we  observe  the  excursions  of 
the  diaphragm,  the  expansion  and  retraction  of  the  lungs  and  ribs,  the 
different  phases  of  the  cardiac  cycle,  and  the  pulsations  of  the  aorta. 

The  fluoroscopic  interpretation  is  not  the  work  of  the  novice.  The 
beginner  should  first  study  the  thoracic  viscera  fluoroscopically  upon  thin 
subjects  and  children,  so  as  to  accustom  himself  to  the  appearances 
presented  normally. 

The  two  methods  of  examination  are  with  the  fluoroscope  and  the 
skiagram.  The  advantages  of  the  fluoroscope  are  these ;  it  is  inexpen- 
sive, easy  of  application,  the  part  may  be  viewed  from  any  direction, 
the  intensity  of  the  rays  can  be  altered,  the  position  of  the  patient,  tube, 
and  fluoroscope  can  be  changed,  movements  of  the  thorax  and  its  con- 
tained viscera  can  be  studied  and  tracings  made  of  their  shape,  size,  and 
position.  The  disadvantages  are  the  liabilities  to  burns,  the  lack  of 
differentiation  of  the  tissues  of  slightly  varying  densities,  and  the  fact  that 
the  image  is  only  transient. 

I.  Fluoroscopic  Examinations. 

Anterior  and  Posterior  Views. — The  screen,  in  an  anterior  view  of  the 
chest,  shows  a  dark  zone  extending  from  the  base  of  the  neck  to  the 
diaphragm,  a  little  to  each  side  of  the  median  line  of  the  body ;  this  is 
the  shadow  cast  by  the  dorsal  vertebra,  sternum,  and  heart.  On  both 
sides  of  this  dark  zone  are  the  much  lighter  shadows  produced  by 
the  lungs ;  traversing  the  lung  shadows,  on  both  sides  from  the  shadow 
cast  by  the  spine,  are  successive  darker  bands,  the  ribs.  The  heart's 
pulsations,  its  position,  shape,  and  size  can  all  be  viewed  by  careful  screen 
examinations.  The  ventricular  chambers  always  present  a  dark  shadow, 
the  right  auricle  giving  usually  a  lighter  shadow  than  the  left.  Above 
the  shadow  of  the  ventricles  and  slightly  to  the  left  is  the  shadow  of  the 
pulmonary  artery.  In  the  first  left  intercostal  space  may  be  seen  a  part 
of  the  arch  of  the  aorta.  The  shadow  of  the  heart's  apex  will  be  observed 
to  blend  with  the  shadow  of  the  diaphragm.  The  border  of  the  pulsating 
306 


APPLICATION  OF  THE  X-RAYS.  307 

heart  presents  a  slightly  lighter  shadow  than  its  interior.  The  cardiac 
outline  is  best  viewed  through  the  anterior  thoracic  wall.  A  posterior 
view  of  the  heart  is  less  distinct,  because  of  the  intervening  spine  and 
lungs  and  of  its  anterior  position  in  the  chest  cavity. 

In  a  posterior  view,  a  dark  shadow  corresponding  to  the  left  side  of 
the  heart  is  seen  to  the  left  of  the  spine,  and  a  smaller  and  slightly  less 
distinct  but  denser  shadow  of  the  right  auricle  is  seen  to  the  right  of  that 
produced  by  the  spine.  The  organs  of  the  thorax,  represented  on  the 
screen,  may  be  easily  recorded  in  the  following  manner  :  The  operator 
should  employ  a  screen  of  sufficiently  large  dimensions  to  cover  the  entire 
chest,  and  upon  whose  dorsal  aspect  has  been  placed  a  sheet  of  white  linen 
writing  paper.  In  order  to  maintain  a  constantly  steady  position  of  the 
screen  for  a  uniform  and  correct  tracing,  the  patient  should  be  seated 
comfortably,  so  that  he  may  not  move.  The  screen  should  be  supported 
by  a  movable  frame  fastened  to  the  arm,  coining  from,  a  metallic  upright 
free  from  all  undue  vibrations,  as  otherwise  the  examination  will  prove 
unsatisfactory.  The  screen  having  been  placed  either  in  front  or  in  back 
of  the  patient's  thorax  (leaving  1  inch  (2.5  cm.)  space  between  the  screen 
and  chest),  we  are  ready  to  trace  on  the  paper  the  image  cast  on  the 
screen  by  the  use  of  an  opaque  pencil,  preferably  one  that  is  indelible.  I 
believe,  however,  that  the  orthodiagraph  is  always  more  desirable. 

Lateral  and  Oblique  Views. — In  the  lateral  view,  especially  when  seen 
from  the  patient's  left  side,  the  operator  observes  the  heart  in  contact 
with  the  anterior  chest  wall,  also  the  profile  view  of  the  heart,  the  aorta 
arching  backward  to  approach  the  vertebral  column,  and  an  unobstructed 
interval  between  the  posterior  part  of  the  heart  and  the  spine. 

The  oblique  view,  which  can  be  antero- lateral  or  postero- lateral,  right 
or  left,  is  taken  with  the  fluoroscope  at  an  angle  of  about  45°  to  the 
vertical  axis  of  the  body.  This  view  is  of  value  in  an  obscure  diagnosis, 
in  furnishing  additional  and  often  confirmatory  data. 

Examination  of  the  Lungs. — The  image  of  a  normal  lung,  on  a  fluores- 
cent screen  or  fluoroscope,  is  bright,  the  rays  penetrating  with  less  resist- 
ance the  spongy  tissue  than  ordinary  dense  tissue.  This  brightness  of 
the  screen  differs  in  degree  during  the  various  stages  of  respiration. 
When  the  lungs  are  inflated  to  their  fullest  extent,  there  is  represented 
on  the  screen  a  uniform  bright  light  shadow.  At  the  end  of  the  fullest 
expiration  the  above  degree  of  brightness  has  considerably  diminished, 
as  the  lung  tissue  has  become  more  compact.  Between  these  two  extremes 
there  is  a  medium  degree  of  brightness,  obtained  when  respiration  has 
temporarily  been  halted  midway  between  inspiration  and  expiration. 

As  we  would  also  naturally  expect,  in  children  and  in  thin  adults  the 
lungs  appear  brighter  on  the  screen  than  in  muscular  or  corpulent  indi- 
viduals. In  the  latter  class  of  cases,  as  more  tissue  must  necessarily  be 
traversed  by  the  rays,  there  is  more  chance  for  their  absorption,  hence 
the  giving  of  more  "shadow." 


:>(is  ELECTRO-THERAPEUTICS. 

In  examiiiiug  a  lung  from  below  upward,  the  brightness  of  the 
shadow  very  slightly  increases  as  we  approach  the  apex.  Usually  the 
right  lung  presents  a  slightly  lessened  degree  of  shadow  brightness  as 
compared  with  the  left.  The  shadow  of  the  right  apex  in  normal  cases 
is  always  darker  than  the  left.  No  satisfactory  explanation  has  ever 
been  given  concerning  this  difference.  Some  authorities  maintain  that 
it  is  due  to  a  slight  hypertrophy  of  the  muscle  tissue  of  the  right  side 
of  the  chest.  It  is  more  marked  in  right-handed  people,  and  we  might 
naturally  infer  that  the  opposite  would  be  true  in  left-handed  people, 
although  observations  on  such  subjects  have  also  proved  the  contrary  to 
be  the  case. 

Normal  Heart  and  Diaphragm. — Dr.  F.  H.  Williams1  states  that  the 
radioscopic  appearances  of  the  normal  heart  and  diaphragm  as  seen  by 
a  screen  examination  in  the  anterior  view  are  the  following  : 

"  In  health  the  diaphragm  moves  as  follows  :  Quiet  breathing,  one- 
half  inch  (1.3cm.)  ;  at  full  inspiration  2£  to  3  inches  (6.5-7.5  cm.),  and 
slightly  more  on  the  right  than  on  the  left  side.  A  part  of  the  aorta  in 
some  patients  may  be  observed  in  the  first  intercostal  space  ;  in  the  sec- 
ond intercostal  space  a  portion  of  the  pulmonary  artery  ;  the  left  border  of 
the  ventricle  is  chiefly  seen  during  a  full  inspiration,  when  the  apex  and 
a  portion  of  the  lower  border  are  also  visible ;  the  maximum  pulsation 
is  at  a  point  corresponding  to  the  cavity  of  the  ventricle,  about  where  its 
outline  crosses  the  fourth  rib  ;  during  full  inspiration  the  heart  moves 
downward  to  the  sternum.  To  the  right  of  the  sternum  the  outline  of 
the  large  vessels  is  seen  and,  less  distinctly,  the  right  auricle  between  the 
second  and  fourth  ribs.  The  right  auriculo- ventricular  line  curves,  with 
a  slight  indentation,  from  the  second  to  the  sixth  ribs  inclusive.  During 
the  momentary  elevation  of  the  diaphragm  this  line  is  pushed  upward 
and  outward.  During  a  forced  depression  of  the  diaphragm  it  elongates 
and  is  carried  downward  and  inward  toward  the  sternum.  Under  ordi- 
nary conditions  we  find  the  lowermost  portion  of  the  heart's  shadow  fus- 
ing with  that  of  the  liver  and  the  diaphragm." 

Dr.  Albert  Abrams*  says  :  "The  average  normal  excursion  of  the 
diaphragm  in  quiet  breathing  is  five-eighths  of  an  inch  or  1J  cm.;  between 
full  inspiration  and  expiration,  on  the  right  side,  2 1  inches  or  (about)  6.7 
cm. ;  left  side,  2f  inches  or  7  cm. 

"In  long-chested  persons  diaphragmatic  excursions  are  greater  than 
in  short  persons  with  deep  chests." 

Measurement  of  the  Diaphragmatic  Incursion. — Dr.  H.  Guilleniinot 3 
says:  "On  account  of  the  slope  of  the  diaphragm  backward  and  down- 
ward, the  highest  point  of  the  diaphragmatic  arch  is  nearer  the  anterior 
than  the  posterior  surface  of  the  body.  Moreover,  the  point  of  contact 

1  The  Rontgen  Rays  in  Medicine  and  Surgery. 

7  Journal  of  the  American  Medical  Association,  May  3,  1902. 

3  Archives  of  the  Rontgen  Ray,  January,  1906. 


APPLICATION  OF  THE  X-RAYS.  309 

of  the  tangent  ray  is  displaced  with  the  movement  of  the  diaphragm, 
and  this  displacement  varies  with  the  subject  and  with  the  distance  of 
the  anti-cathode.  All  these  cases  of  error  are  avoided  by  the  use  of 
orthodiascopy/'  He,  in  collaboration  with  M.  Yauuier,  obtained  a 
tabulation  of  23  cases,  comprising  normal  lungs  and  tuberculous  lungs  in 
every  stage.  From  their  observations  they  arrived  at  the  following 
conclusions : 

1.  il  On  the  right  side  the  mean  position  of  the  diaphragmatic  curve 
is  16.5  cm.  below  the  suprasternal  line,  and  on  the  left  side  it  is  18.5 
cm.  below  that  line. 

2.  "The  normal  amplitude  of  the  diaphragmatic  incursion  is  from 
16  to  18  mm.     It  is  approximately  equal  on  the  two  sides. 

3.  "  Any  variation  in  the  amount  of  the  incursion  on  the  right  and 
left  sides  is  a  pathological  symptom,  and  in  most  cases  has  a  serious 
clinical  significance. 

''The  ratio  between  the  amplitude  of  the  diaphragmatic  incursion 
and  the  costal  angle  depends  greatly  on  the  type  of  respiration,  whether 
costal  or  abnormal. 

'•  The  inequality  of  the  incursion  of  the  diaphragm  on  the  right  and 
left  sides  is  an  important  aid  to  diagnosis." 

The  Measurement  of  the  Costal  Angle. — Guilleminot  has  shown  the 
possibility  of  radiographing  the  thorax  in  inspiration  or  in  expiration. 
This  may  be  accomplished  by  dissociating  the  phases  of  inspiration  and 
of  expiration  by  means  of  an  automatic  interrupter.1  By  this  means, 
one  can  obtain  a  cinemato-radiograph  of  the  respiration.  On  these 
radiographs  one  may  measure  the  obliquity  of  the  ribs  between  two- 
points  on  the  upper  margin  of  the  rib  at  a  distance  of  If  and  2i  inches 
i4  and  8  cm.),  respectively,  from  the  median  line.  If  we  now  take  any 
horizontal  line  and  measure  the  vertical  distances  of  these  two  points, 
the  difference  of  the  two  ordinates  will  give  us  the  obliquity  of  the 
rib  for  a  distance  of  4  cm.,  and  this  divided  by  4  will  give  us  the 
obliquity  per  centimetre.  This  is  the  cotangent  of  the  angle  with  the 
vertical,  made  by  a  line  passing  through  the  given  points. 

"By  this  means  it  is  easy  to  determine  the  costal  angles  of  inspira- 
tion and  of  expiration.  Their  difference  is  the  functional  costal  angle, 
which  may  vary  from  3°  to  5°. 

"The  orthodiascopic  procedure  is  much  more  simple. 

•  •  With  practice  one  is  able  to  distinguish  the  projection  of  the  up- 
per border  of  a  rib  at  its  position  of  maximum  elevation  and  depression 
while  the  patient  breathes  rather  deeply. 

11  In  each  case  it  is  important  to  note  accurately  the  physiological 
type  of  the  respiration,  which  may  vary  in  all  possible  degrees  between 
the  abdominal  and  the  superior  costal  type.  For  this  purpose  the 

1  Comptes-rend.  Acad.  Science,  June  12,  1899. 


310  ELECTRO-THERAPEUTICS. 

tracing  of  the  costal  range  should  be  accompanied  by  a  tracing  of  the 
diaphragmatic  incursion. 

"If  we  take  the  means  of  these  measurements,  we  obtain  the 
following  results  : 

(Inspiration,  77J°  ) 

Left   1  y  Mean  position,  74i|° 

(Expiration,  72|°J 

f  Inspiration,  76}  °1 

Right   <  .Mean  position,  74f  ° 

(Expiration,  73  °j 

"In  these  observations  the  mean  angle  is  the  angle  which  the 
rib  makes  with  the  vertical  when  it  is  in  a  position  midway  bet  worn 
inspiration  and  expiration. 

"The  absolute  coincidence  of  the  mean  angles  on  the  right  and  left 
sides  is  certainly  accidental,  there  being  considerable  divergence  in  cer- 
tain instances. 

"The  mean  costal  angle  may  therefore  be  said  to  be  approximately 
equal  on  the  two  sides,  and  to  be  about  74°  to  75°. 

(  Left,  78.6°  } 
Inspiration  \  }•  Mean,  78.2°  ^ 

(  Right,  77.8°  j 

j-  Difference  =  5.4° 

(  Left,  72.7°  ) 
Expiration  \  V  Mean,  72.8°  j 

(  Right,  72.9°  J 

"The  functional  costal  angle,  therefore,  in  healthy  subjects  is  equal 
on  the  right  and  left  sides,  and  usually  varies  between  5°  and  6V 

Causes  of  the  Restriction  of  the  Diaphragmatic  Wave. — Albert  Abrams1 
says,  in  this  connection:  "The  restricted  diaphragmatic  movements 
must  be  regarded  as  very  suspicious  of  phthisis.  This  sign,  first  referred 
to  by  Williams,  of  Boston,  has  had  no  theory  advanced  to  explain  its 
existence.  I  will  briefly  summarize  my  investigations  which  gave  birth 
to  the  theory  that  an  emphysematous  condition  of  the  lungs  exists  in 
phthisis.  Rokitansky  and  Brehmer  noted  that  lungs  too  voluminous 
coupled  with  a  small  heart  characterized  the  phthisical  habitus.  If  the 
physician  were  to  depend  on  percussion  dulness  as  an  evidence  of  early 
phthisis,  the  affection  would  never  be  recognized  ;  lung  resonance,  not 
dulness,  is  the  early  physical  sign  of  phthisis.  The  rays  are  invaluable 
in  the  recognition  of  emphysema ;  in  this  condition,  the  lungs  seem  too 
large  for  the  chest,  the  diaphragm  is  low  and  its  excursions  restricted." 

Diseases  of  the  Diaphragm.  —  "In  spasm,"  says  Abrams,  "dia- 
phragmatic movements  are  practically  suspended  on  the  affected  side. 

'Journal  of  the  American  Medical  Association,  May  3,  1902. 


APPLICATION  OF  THE  X-EAYS.  311 

Suddenly  the  diaphragm  contracts  and  descends  several  inches  below  its 
normal  descent.  Singultus  may  accompany  the  descent,  whilst  cyanosis 
and  dyspnoea  become  intense.  In  paralysis,  movements  of  diaphragm 
on  the  affected  side  are  suspended  ;  during  inspiration,  the  midriff  rises. 
In  diaphragmatic  pleurisy,  movements  of  the  diaphragm  are  very  much 
restricted  or  even  suspended.  The  upper  part  of  the  lung  is  brighter 
than  normal,  owing  to  over-disteution. 

li  Average  Normal  Excursion  of  the  Diaphragm. — In  quiet  breathing, 
li  centimeters  ;  between  full  inspiration  and  expiration,  6.7  cm.  on  the 
right  side  and  about  7  cm.  on  the  left  side.  In  long-chested  persons 
the  diaphragmatic  excursions  are  greater  than  in  short  persons  with 
deep  chest. 

"  Width  of  the  Normal  Heart. — With  the  screen  about  75  cm.  from 
the  tube  and  with  the  target  directed  toward  a  point  where  the  median 
line  is  crossed  by  the  fourth  rib,  the  right  heart  measures  3  cm.  from  the 
median  line,  and  the  left  heart  8.5  cm.  from  the  median  line  ;  a  total 
of  11.5  cm." 

II.  Skiagraphic  Examinations. 

The  lungs  may  be  examined  in  two  ways,  fluoroscopically  and  skia- 
graphically.  What  is  stated  below  regarding  the  methods  of  examination 
is  equally  true  for  both  the  normal  and  abnormal  lung. 

Position  of  the  Patient. — Skiagrams  of  the  lungs  may  be  made  with  the 
patient  either  in  the  sitting,  semi-recumbent,  or  dorsal  decubitus  posture. 
In  my  experience  the  latter  has  always  proved  to  be  the  more  satisfactory 
of  the  two.  The  patient  is  requested  to  remove  all  clothing  covering  the 
thorax,  in  some  cases  not  even  permitting  the  retention  of  a  garment 
next  to  the  skin. 

When  the  dorsal  decubitus  position  cannot  be  taken,  the  patient 
starting  to  cough,  or  if  he  is  suffering  from  dyspnoea,  he  should  be  re- 
quested to  resume  the  semi-recumbent  posture,  having  the  head-end  of 
the  table  elevated  to  an  angle  of  45°,  so  as  to  insure  greater  comfort  and 
also  in  a  measure  to  remove  the  pressure  exerted  upon  the  diaphragm 
and  the  adjacent  lungs.  I  always  request  the  patient  to  elevate  the  arms 
and  clasp  the  hands  over  the  head,  in  order  to  raise  the  scapulae  and 
thus  remove  their  shadows  from  the  shadow  of  the  thorax. 

Place  two  superimposed  sensitive  plates,  well  protected  by  a  thin 
layer  of  celluloid,  under  the  patient's  thorax.  The  size  of  the  plates 
employed  will  depend  upon  the  size  of  the  patient's  chest ;  the  plate 
should  be  slightly  larger  than  the  chest  itself  so  as  to  extend  on  both 
sides  about  two  inches  beyond  its  outer  margins. 

The  tube  should  be  placed  with  the  target  pointing  directly  toward 
the  centre  of  the  whole  thorax  and  from  20  to  25  inches  (50  to  63  cm. ) 
distant  from  the  plate,  depending  upon  the  thickness  of  the  chest  and  the 


312 


ELECTKO-THERAPEUTICS. 


penetrative  power  of  the  tube.  The  cathode  stem  of  the  tube  should 
extend  toward  the  foot  end  of  the  table,  to  prevent  alarming  the  patient 
by  the  sparking  that  necessarily  occurs  in  self-regulating  tubes. 


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q/7  Exposure. — Exposure  should  be  as  rapid  as  possible,  other- 
wise the  incessant  motions  of  the  thoracic  viscera  will  cause  a  blurred 
shadow.  Formerly  this  obstacle  was  partially  overcome  by  telling  the 
patient  to  take  a  deep  inspiration  and  to  "hold  "  the  breath.  I  then  took 
a  short  exposure  (5  or  10  seconds),  repeating  the  process  five  or  six  times 
in  one  or  two  minutes.  But  this  method  has  been  greatly  improved  upon, 
by  the  instantaneous  process.  Radiographs  of  the  thorax  have  been 
made  by  Von  Ziemssen  and  Eieder  in  one  second  of  time,  by  the  appli- 
cation of  the  Eosenthal  method.1  Rosenthal  employs  a  Volt-Ohm  appa- 
ratus, with  a  60  centimetre  coil,  an  electrolytic  interrupter,  and  a  Volt- 
Ohm  tube.  The  time  of  exposure  is  shortened  by  the  use  of  two  intensi- 
fying screens,  one  being  placed  with  its  coated  side  against  the  coated 
side  of  the  film  and  the  Schleussner  film  then  laid  between  the  intensi- 
fying screens,  the  coated  sides  of  which  are  toward  the  photographic 
film.  These  are  then  enclosed  in  three  light  tight  envelopes.  The  pa- 
tient lies  on  his  abdomen  or  back  upon  the  photographic  plate,  or  the 

1  Miinchener  medicinische  Wochenschrift,  1899,  No.  32. 


APPLICATION  OF  THE  X-EAYS.  313 

plate  is  placed  upon  the  particular  part  desired  to  be  photographed,  and 
the  current  is  opened  for  a  moment  and  as  quickly  closed.  The  plates 
are  then  removed  and  developed  in  the  usual  manner.1 

III.   Clinical  Applications. 

A.  DISEASES  OF  THE  BRONCHI  AND  LUNGS. 

The  X-rays  have  proved  themselves  invaluable  in  diagnosticating 
pulmonary  affections  and  conditions,  affording  in  many  cases  confirm- 
atory evidence  and  guiding  the  practitioner  in  numerous  incipient  condi- 
tions into  a  correct  understanding  of  the  pathological  changes  present. 
Early  in  the  progress  of  pulmonary  diseases,  where  marked  changes  are 
not  fully  in  evidence,  the  usual  physical  methods  employed  often  fail  to 
elicit  the  proper  pathognomonic  signs,  and  it  is  here  that  the  X-rays  serve 
as  a  most  valuable  adjunct. 

Bronchitis. — Most  cases  of  bronchitis  fail  to  show  the  normal  bright- 
ness of  the  lung,  when  free  secretion  is  once  established.  The  character- 
istic clouding  is  usually  limited  to  the  lower  two-thirds  of  both  lungs. 
In  this  affection  the  excursions  of  the  diaphragm  are  usually  unrestricted, 
except  where  the  smaller  bronchial  tubes  are  obstructed  by  an  exudate. 
If  the  patient  is  instructed  to  cough,  the  secreted  material  may  be  expec- 
torated or  else  temporarily  removed  from  the  lower  portion  of  the  lung  ; 
thus  permitting  the  excursions  of  the  diaphragm  to  be  more  perfectly 
restored.  In  chronic  bronchitis,  with  considerable  coughing,  there  is 
likely  to  be  some  dilatation  of  the  right  ventricle.  If  the  bronchitis  is  of 
tuberculous  origin,  small  shadows  of  the  involved  areas  are  usually  con- 
fined to  the  apical  regions.  In  bronchitis  associated  with  influenza,  a 
few  localized  shadows  may  be  discerned,  which  are  really  the  complicat- 
ing foci  of  a  lobular  pneumonia. 

Bronc/iicctftxis. — This  condition  in  itself  does  not  produce  any  shadows 
on  the  screen  or  skiagram,  unless  the  adjacent  lung  tissue  is  consolidated 
or  infiltrated  with  calcareous  substances.  When  studying  this  condition, 
the  patient  should  be  examined  in  various  positions  and  from  all  direc- 
tions. The  shadows  of  brouchiectatic  areas  are  generally  found  in  the 
middle  and  lower  thirds  of  the  lung,  and  are  usually  posterior.  In  un- 
complicated cases  of  bronchiectasis  there  are  no  causes  for  restriction  in 

1  In  1905,  during  the  Rontgen  Congress  in  Berlin,  Drs.  Rosenthal  and  Rieder,  of 
Munich,  exhibiu-d  skiagrams  of  thoraxes  which  were  taken  with  an  exposure  of 
one-tenth  ( j<y)  °f  a  second. 

In  1901,  Mr.  Isenthal  (Archives  of  the  Rontgen  Ray,  vol.  v.,  Xo.  5)  exhibited  in 
London  instantaneous  skiagrams  ;  in  1904,  Dr.  Henry  Hulst,  of  Grand  Rapids,  Mich., 
read  a  paper  before  the  American  Rontgen  Ray  Society  in  which  he  likewise  showed 
instantaneous  skiagrams  of  the  thorax  ;  in  1904  I  experimented  with  different  methods 
on  the  same  patient  at  the  Philadelphia  Hospital,  and  arrived  at  the  above  conclu- 
sions. See  tabulation,  page  312.  (Transactions  of  the  American  Rontgen  Ray  Soci- 
ety, 1904.) 


314  ELECTRO-THERAPEUTICS. 

the  movements  of  the  diaphragm.  If,  however,  an  emphysema  be  pres- 
ent, then  the  excursions  will  be  restricted,  and  the  midrift'  will  be 
observed  to  occupy  a  lower  position.  As  a  result  of  a  purely  brouchiec- 
tatic  condition,  the  heart  very  rarely  changes  its  shape,  size,  or  position. 
If  such  a  cavity  is  healing,  a  considerable  quantity  of  scar  tissue  is 
gradually  developed,  which,  by  contraction,  may  displace  the  heart 
from  its  normal  position.  In  a  complicating  emphysema  the  heart  is 
displaced  by  the  latter  and  not  by  the  bronchiectatic  disease.  If  the 
chest  is  examined  before  the  bronchiectatic  cavity  has  been  emptied 
by  coughing  (the  best  time  for  examination  of  this  condition  being 
after  the  patient  has  been  resting  in  the  recumbent  position  for  several 
hours),  a  distinct  shadow  corresponding  to  the  cavity  is  very  easily 
seen,  followed  by  a  brighter  appearance  as  soon  as  the  contents  have 
been  evacuated. 

D.  B.  King1  furnishes  notes  on  20  cases  studied  by  the  Pontgen  rays, 
in  addition  to  the  other  usual  methods  of  examination.  In  each  instance 
the  endeavor  was  made  to  detect  the  presence  or  absence  of  (1)  dilated 
bronchi.  In  advanced  cases  where  the  bronchi  were  much  dilated,  as 
shown  by  the  stethoscope  or  at  autopsy,  the  Rontgen  rays  failed  to  reveal 
their  presence.  (2)  In  cases  of  saccular  cavities.  Here  the  rays  failed  to 
reveal  such  cavities,  probably  because  of  the  associated  fibrosis  of  the 
lung.  (3)  The  condition  of  the  lung  tissue.  Fibrosis  of  the  lung  was 
shown  by  increased  intensity  of  the  shadows.  (4)  The  presence  of  foreign 
bodies.  .  For  the  detection  of  foreign  bodies  in  the  bronchi,  the  rays  are 
of  undoubted  value.  (5)  Study  of  the  action  of  the  diaphragm.  This  \\  as 
found  to  be  impaired  or  obscured,  depending  upon  the  degree  of  change 
in  the  lung.  King  states  that  the  general  value  of  Rontgen  ray  examina- 
tion in  cases  of  bronchiectasis  is  sufficient  to  warrant  its  employment  on 
more  than  one  occasion,  though  this  may  give  no  further  information  as 
to  the  real  nature  of  the  case  than  is  furnished  by  ordinary  clinical 
methods. 

Asthma.  —  In  asthma  the  lungs  cast  a  brighter  shadow  than  the 
normal,  extending  higher  up  and  lower  down  in  the  thoracic  cavity. 
The  position  of  the  diaphragm  is  observed  to  be  low,  and  its  movements 
much  retarded.  It  is  interesting  to  study  a  paroxysm  of  asthma 
while  the  rays  are  penetrating  the  thorax.  Such  a  paroxysm  can  be 
provoked  by  injecting  cold  water  into  the  nasal  chambers  or  by  packing 
the  nostrils  with  cotton.  During  a  paroxysm,  the  lungs  look  very 
similar  to  the  condition  seen  in  emphysema,  differing  however  from  the 
latter  in  that  there  is  a  complete  fixation  of  the  diaphragm  ;  the  disap- 
pearance of  the  paroxysms  being  evidenced  by  the  restoration  of  the 
lungs  to  their  natural  shadow  brightness.  The  heart  occupies  a  1<>\\<  i 
position  and  moves  less  frequently  during  inspiration  than  it  does 

'The  Practitioner,  February,  1904. 


APPLICATION  OF  THE  X-RAYS.  315 

normally;  the  right  ventricle  is  much  increased  in  si/c.  and  the  outlines 
of  the  heart  are  unusually  clear  cut  and  sharp,  owing  to  the  brightness 
of  the  lungs  during  a  paroxysm. 

Emphysema. — In  this  affection  the  pulmonary  area  is  increased,  and 
when  viewed  with  a  screen  it  is  much  lighter  than  is  the  normal  lung. 
This  area  of  brightness  reaches  high  above  the  clavicles,  and  at  the  same 
time  it  extends  downward,  depressing  the  diaphragm.  It  is  said  by  some 
that  the  diaphragm  presents  two  more  or  less  distinct  curves  (one  on  each 
side),  instead  of  one  large  curve  as  is  seen  normally. 

During  ordinary  quiet  breathing,  the  diaphragm  appears  to  descend 
very  low  in  the  thorax,  though  in  a  forced  expiration  it  ascends  to  a 
higher  level.  In  pneumonia  of  one  lung  there  is  generally  a  compensatory 
emphysema  of  the  other,  the  emphysematous  lung  appears  much  brighter 
on  the  screen  than  it  does  in  health.  The  area  of  the  heart  when  viewed 
with  the  screen  is  very  nicely  defined  in  emphysema.  The  dark  shadow 
produced  by  the  heart  stands  out  boldly  against  the  much  lighter  field 
produced  by  the  emphysematous  lung.  The  heart  occupies  a  lower 
position  in  the  chest  and  assumes  a  more  vertical  direction  than  when  the 
lung  is  normal.  In  the  severer  type  of  emphysema  the  screen  shows 
both  the  right  auricle  and  the  right  ventricle  to  be  much  enlarged.  If 
tuberculosis  is  a  complication,  the  pulmonary  brightness  appears  spotted 
by  irregular  darkened  shadow  areas,  usually  confined  to  one  or  the  other 
apex  and  occasionally  involving  both. 

Broncho- Pneumonia. — In  broncho-pneumonia  circumscribed  shadows 
widely  scattered  throughout  the  lungs  are  observed  on  the  screen,  with 
an  occasional  coalescence  of  the  circumscribed  foci.  Under  such  circum- 
stances the  shadows  are  usually  limited  to  the  middle  and  lower  lobes  and 
are  seldom  found  in  the  apical  regions.  The  diaphragm  frequently 
occupies  a  very  high  position,  especially  during  inspiration,  with  great 
restriction  of  diaphragmatic  movements.  If  there  are  no  complications, 
the  heart  does  not  change  its  position.  Shadows  are  occasionally  pro- 
duced in  certain  portions  by  the  collapse  of  the  lung  tissue;  coughing  and 
deep  breathing  cause  their  evanescence. 

Pulmonary  Tuberculosis.  —  The  shadow  on  the  screen  of  an  early 
pulmonary  tuberculous  lesion  is  difficult  of  interpretation. 

Two  very  important  signs  that  may  be  elicited  by  the  rays,  are  a 
slightly  restricted  diaphragmatic  movement  on  the  involved  side  (Wil- 
liams' sign),  and  the  hazy,  darkened,  and  occasionally  emphysematous 
appearance  of  the  lungs.  As  restricted  movements  of  the  diaphragm 
frequently  indicate  an  incipient  tuberculosis,  they  should  always  be  re- 
garded with  suspicion. 

To  determine  the  presence  of  Williams'  sign,  first  view  the  excursions 
of  the  diaphragm  during  ordinary  breathing,  and  mark  the  highest  ele- 
vation on  the  lower  chest  by  means  of  an  indelible  pencil.  This  tracing 
should  be  made  on  both  sides  of  the  chest  wall.  This  quiet  breathing 


316  ELECTRO-THERAPEUTICS. 

should  be  followed  by  a  full,  deep  inspiration,  and  the  lowest  point  to 
which  the  diaphragm  descends  should  be  noted  in  a  similar  manner,  and 
likewise  on  both  sides. 

Two  or  three  deep  inspirations  successively  following  one  another 
may  be  necessary  to  bring  out  the  lowest  point  to  which  the  diaphragm 
descends.  The  patient  next  expires  as  deeply  as  possible,  and  the 
highest  point  attained  by  the  diaphragm  is  traced  in  a  similar  manner. 
When  the  excursion  from  a  deep  expiration  to  a  deep  inspiration  is 
diminished  on  one  or  the  other  side,  there  is  also  a  diminished  excursion 
of  the  diaphragm  during  ordinary  breathing  on  the  affected  side.  The 
fact  that  the  diaphragm  rises  somewhat  higher  on  the  side  of  the  lesion 
during  a  forced  expiration,  should  not  be  overlooked.  In  advanced 
cases  of  tuberculosis  the  side  of  the  diaphragm  corresponding  to  the 
affected  side  always  rises  much  higher  than  does  the  normal  side,  though 
at  the  same  time  the  excursion  up  and  down  is  continually  diminished. 
If  one  lung  is  partially  or  wholly  diseased,  the  diaphragmatic  excursion 
on  the  sound  side  is  slightly  increased,  as  compared  with  the  affected 
side.  The  higher  position  of  the  diaphragm  taken  in  advanced  cases, 
would  seem  to  be  due  to  a  degeneration  or  shrinkage  of  the  lung  tissue 
on  the  diseased  side ;  the  excursions  may  also  be  diminished  during 
respiration  by  adhesion  between  the  lung  and  diaphragm,  or  by  an 
increased  quantity  of  air  entering  the  organ,  resulting  from  a  paren- 
chymatous  destruction,  etc.  An  exact  study  of  the  diaphragm's  move- 
ments is  perhaps  most  satisfactorily  conducted  by  a  careful  fluoroscopic 
examination. 

The  hazy,  darkened  appearance  of  pulmonary  lesions,  especially 
of  the  incipient  tuberculous  stage,  should  always  be  studied  from 
above  downward,  commencing  at  the  apices.  All  hazy,  darkened 
areas  on  the  screen  should  be  outlined  on  the  skin  by  an  indelible  pencil 
or  crayon. 

These  are  usually  brought  out  more  distinctly  after  a  full  inspira- 
tion. In  attempting  to  detect  such  a  hazy  area  at  the  apex  or  in  a  lobe, 
the  patient  should  be  requested  to  droop  the  shoulder  on  the  side  under 
examination,  so  that  the  shadow  produced  by  the  clavicle  may  l»e 
lowered  out  of  the  field  as  much  as  possible.  A  better  view  of  the 
affected  field  may  be  obtained  by  having  the  patient  stoop  forward, 
allowing  the  rays  to  enter  the  thorax  at  the  mid-scapular  region,  placing 
the  screen  directly  over  the  supraclavicular  space.  The  examiner  should 
(•(.in pare  the  light  produced  by  the  two  apices  both  during  full  inspira- 
tion and  during  deep  expiration.  The  light  coming  from  the  tube  should 
be  so  regulated,  by  increasing  or  decreasing  the  distance  between  the  tube 
and  patient,  that  the  affected  side  is  only  faintly  illuminated.  When  the 
two  sides  are  now  compared,  the  sound  side  appears  slightly  brighter 
than  the  other.  The  excitation  of  the  tube  may  be  controlled  partly,  by 
a  speed  regulator  or  by  a  rheostat,  but  these  are  seldom  required. 


APPLICATION   OF  TIIK  X-RAYS.  317 

When  both  apices  are  involved  in  a  tuberculous  process,  usually  one 
apex  is  more  extensively  affected  than  the  other,  t.  r.,  there  is  distinctly 
more  haziness  on  the  side  most  affected.  A  clouded  appearance  of  both 
apices  is  indicative  of  an  already  advanced  form  of  tuberculosis.  In  the 
early  stages  of  this  disease,  an  associated  einphysematous  condition 
of  the  lungs,  occurring  in  the  middle  and  lower  thirds,  may  be 
demonstrated. 

The  value  of  the  X-rays  in  incipient  pulmonary  tuberculosis  may  be 
well  illustrated  by  the  reports  of  the  following  cases  iu  the  service  of 
Prof.  James  M.  Anders,  which  were  under  my  care  for  a  skiagraphic 
examination.1 

CASE  I. — S.  H.,  female,  married,  aged  28  years,  cigar- maker,  first 
applied  at  the  out-patient  clinic  of  the  Medico-Chirurgical  Hospital, 
Philadelphia,  June  6,  1899,  for  treatment.  A  brother  died  of  acute 
phthisis.  The  patient  had  had  some  of  the  diseases  of  childhood  ;  but 
the  remainder  of  her  history  was  negative.  Her  illness  began  with 
paroxysmal  pains  in  the  praecordia,  and  this  lasted  for  a  considerable 
period.  The  day  previous  to  her  visit  she  had  expectorated  blood,  which 
she  stated  was  coughed  up  ;  the  quantity  of  blood  was  small,  bright  red, 
and  frothy.  The  abnormal  physical  signs  were  an  impairment  of  the 
percussion- note  and  harsh  breathing,  with  prolonged  high-pitched  ex- 
piration at  the  right  apex,  with  absence  of  the  vesicular  quality,  and 
prolonged  high-pitched  expirations  at  left  apex  ;  all  signs,  however,  were 
less  marked  than  at  right  apex.  Microscopic  examination  of  the  spu- 
tum gave  a  negative  result.  Later  an  X-ray  examination  revealed  an 
abnormal  shadow  or  marked  haziness  at  the  apices  of  both  lungs,  but 
more  marked  at  the  right. 

CASE  II. — P.  K.,  aged  29  years,  cigar- maker,  applied  for  treatment  at 
the  out-patient  clinic  of  the  Medico-Chirurgical  Hospital,  November  10, 
1899.  The  family  history  is  entirely  negative  as  to  pulmonary  diseases. 
The  patient  suffered  none  of  the  diseases  of  childhood.  He  had  had 
typhoid  fever  one  and  a  half  years  previously,  which  confined  him  to  bed 
for  ten  weeks.  Since  then  he  had  been  complaining  of  persistent  gastric 
disturbance,  evidenced  by  eructations  of  gas  and  dull  pains  in  the 
epigastrium  after  meals  ;  there  had  been  some  dyspnoea  on  exertion,  and 
at  intervals  cardiac  palpitation.  A  few  days  prior  to  his  first  visit,  he 
began  to  expectorate  bright-red  blood.  Subsequently  there  was  neither 
cough  nor  expectoration.  The  amount  of  blood  lost  did  not  exceed  half 
an  ounce.  An  examination  of  the  throat  and  larynx  was  negative,  and 
the  same  was  true  of  a  physical  examination  of  the  thorax,  although  the 
chest  was  of  the  paralytic  or  phthisical  type.  After  excluding  all  causes 
of  haemoptysis,  except  pulmonary  tuberculosis,  an  X-ray  picture  was 

1  Journal  of  the  American  Medical  Association,  January  12,  1901,  and  reported  by 
me  to  the  American  Congress  of  Tuberculosis,  May  14,  1902. 


318  ELECTRO-THERAPEUTICS. 

made.     This  showed  commencing  consolidation  over  circumscribed  areas 
011  both  sides  just  below  the  apices. 

CASE  III. — J.  O.,  aged  14  years,  errand  boy,  was  admitted  to  the 
wards  of  the  Medico-Chirurgical  Hospital,  November  13,  1899.  Father 
died,  in  his  fifty-second  year,  of  heart  and  lung  disease,  the  precise  nature 
of  which  the  patient  does  not  know.  One  sister  is  in  delicate  health. 
The  lad  had  had  the  usual  diseases  of  childhood  and  a  severe  illness  of 
unknown  character  a  few  years  since  ;  had  always  been  in  delicate  health. 
The  present  illness  began  about  four  weeks  before  he  came  under  my 
observation.  The  first  symptoms  complained  of  were  malaise,  headache, 
a  slight  cough  in  the  evenings  and  mornings,  more  or  less  abdominal 
pains,  associated  with  slight  diarrhoea.  The  evening  temperature  on 
admission  was  on  the  average  about  100°  F.,  but  abdominal  pain,  diarrhoea 
and  cough  had  largely  subsided.  Physical  examination  showed  a  para- 
lytic or  phthisical  thorax,  without  any  other  abnormal  physical  sign. 
After  excluding  typhoid  fever,  latent  tuberculosis  was  suspected  ;  tuber- 
culin was  injected,  followed  by  a  positive  reaction.  An  X-ray  examina- 
tion was  also  made  by  Dr.  Kassabian,  and  showed  a  slight  haziness  below 
the  left  clavicle.  (See  Figs.  177,  178.) 

Cavitation. — As  cavity  formation  begins  in  the  centre  of  a  consoli- 
dated mass,  after  it  has  slightly  advanced  we  may  observe  a  lighter  field 
encircled  by  a  darker  shadow  zone.  If  the  outer  margin  of  the  cavitated 
mass  has  been  infiltrated  with  inorganic  salts,  we  may  demonstrate  on 
the  screen  a  dark,  narrow  border-like  shadow,  encircling  a  larger  light 
field.  If  the  cavity  is  filled  with  exudative  material,  there  will  be  no 
light  reflex,  presenting  the  appearance  of  a  consolidated  mass.  This 
would  also  be  true  if  the  entrance  to  the  cavity  were  located  at  the  upper 
surface.  In  some  instances  this  fluid  can  be  readily  removed  by  having 
the  patient  lie  down  and  cough,  when  the  light  reflex  may  be  noted  to 
again  return.  A  dilated  bronchus,  with  exudative  material  and  consoli- 
dated structure  surrounding  it,  cannot  be  differentiated  from  a  small 
cavity  by  means  of  the  X-rays.  Where  the  cavity  is  small  and  the  wall 
thickened,  little  or  no  light  reflex  may  be  visible  on  either  the  screen  or 
skiagram. 

As  the  different  pictures  of  pulmonary  tuberculosis  presented  by  the 
screen  and  skiagram  bear  a  striking  similarity  to  other  lung  affections, 
the  employment  of  special  methods  for  more  accurately  determining  and 
differentiating  the  true  condition  would  seem  of  first  importance.  Thus, 
Dally,1  who  has  made  a  great  many  pulmonary  examinations  by  means 
of  the  X-rays,  states  that  the  earliest  indication  of  pulmonary  tubercu- 
losis is  the  unilateral  limitation  or  loss  of  mobility  of  the  diaphragm. 
Prior  to  any  shadow  production  (the  result  of  tuberculous  involvement) 
the  action  of  the  diaphragm  becomes  gradually  lessened  on  the  affected 

1  Lancet,  June  27,  1900. 


FIG.  177. — Tuberculosis  of  the  right  lung  (posterior  view) ,  and  a  photographic  tracing  of  the  same. 
The  skiagraph  shows  consolidation  of  the  right  apex  and  right  base ;  heart  is  displaced  toward  the 
right.  A,  acromion  process :  Sp,  spinous  process  of  scapula  ;  Cl,  clavicle;  C,  coracoid  process ;  1,  2,  3t 
4,  5,  6,  7,  8,  9,  10,  ribs  (posterior)  ;  I,  II,  III,  IV,  ribs  (anterior). 


FIG.  178.— Tuberculosis  of  the  right  apex  (anterior  view).  Plate  placed  in  front  of  chest.  The 
chest  of  the  same  patient  as  shown  in  Fig.  177.  The  lower  cut  is  a  photographic  tracing  of  the  above. 
Ab,  axillary  border  of  scapula ;  Vb,  vertebral  border ;  S.A.,  superior  angle ;  RD,  right  side  of  the 
diaphragm ;  LD,  left  side ;  T.S.,  triangular  space,  best  seen  with  the  screen  against  the  chest,  between 
the  heart  and  the  diaphragm  (for  the  diameters  of  the  heart,  see  page  330) ;  C,  cavity,  which  was  not 
visible  on  the  posterior  view. 


APPLICATION  OF  THE  X-RAYS.  319 

side.  After  the  tuberculous  process  has  advanced  to  the  point  of  produc- 
ing distinct  cloudy  shadows  within  normal  lung  shadows,  the  limitation 
of  diaphragmatic  movements  usually  becomes  more  and  more  evident ; 
it  may,  however,  decrease. 

Cases  are  reported  where  marked  limitation  in  the  mobility  of  the 
diaphragm  was  present  when  only  the  apical  region  of  the  lung  had  been 
involved.  He  further  states  that  the  typical  shadow  of  an  early  pul- 
monary tuberculous  process  is  irregularly  mottled,  and  that  sucti  an 
appearance  may  be  simulated  by  a  new  growth,  but  the  latter  can  readily 
be  differentiated  by  the  characteristic  distribution  of  the  shadow  and  by 
the  peculiar  physical  signs.  A  consolidated  area  produces  a  shadow  of 
moderate  density,  and  this  in  itself  is  increased  when  the  adjacent  lung 
tissue  is  hypenemic.  He  believes  that  a  caseating  process  throws  a  still 
deeper  and  darker  shadow.  The  appearance  of  cavities  will  vary 
according  to  the  size,  position,  and  whether  filled  or  empty.  Those  empty 
and  located  at  the  apical  region  of  the  lung  are  usually  transradiant ; 
when  filled  with  pus  they  may  remain  unnoticed.  In  brief,  Dally  believes 
that  the  unilateral  limitation  of  diaphragmatic  movement  as  seen  by  the 
fluoroscope  is  very  often  the  earliest  sign  of  a  beginning  pulmonary 
tuberculosis,  and  that  only  by  the  X-rays  can  pulmonary  tuberculosis  be 
diagnosticated  at  an  earlier  stage  than  by  the  other  means  at  the  disposal 
of  the  practitioner. 

Dr.  Dally l  classifies  the  quality  of  the  shadow,  with  the  percussion 
note  manifested,  as  follows  : 


RONTGEN  RAYS.  . 


Brightness  Hyper-resonance 

Transradiancy  z=  Normal  resonance 

Faint  shadow  =  Impaired  resonance 

Dense  shadow  =  Dulness 

Opacity  =  Absolute  dulness 


. .  PERCUSSION  NOTE 


Vieruzhsky,  of  the  Nikolas  Military  Hospital,  which  is  devoted 
especially  to  the  treatment  of  tuberculosis,  reports  elaborately  on  the  re- 
sults obtained  by  the  various  methods  of  diagnosticating  tuberculosis.2 
He  is  enthusiastic  at  the  results  obtained  from  the  use  of  the  Kontgen 
rays  in  the  diagnosis  of  the  early  stages  of  pulmonary  tuberculosis.  The 
use  of  the  spirometer  as  an  agent  assisting  in  the  diagnosis  of  this  disease 
has  not  been  satisfactory,  the  figures  obtained  in  the  measurement  of  the 
respiratory  capacity  of  the  lungs  being  uncertain  and  variable.  He  is 
well  able  to  realize  the  deficiencies  and  limitations  of  the  X-rays,  but 
he  asserts  that  skiagraphy  offers  a  means  of  controlling  and  confirming 
the  data  of  physical  examinations. 

Acute  Mili<iry  Tuberculosis. — This  disease  is  difficult  to  diagnose  clini- 
cally ;  and  it  is  often  overlooked  by  reason  of  the  frequent  absence  of 
physical  signs.  The  only  means  then  left  to  the  practitioner  is  by  an 

1  Lancet,  June  27,  1903.  2  Roussky  Vratch,  April  26,  1903. 


320  ELECTRO-THERAPEUTICS. 

X-ray  examination.  In  this  disease  the  screen  or  skiagram  presents  very 
small  darkened  shadows,  scattered  throughout  the  lung. 

Pneumonia.  —  The  various  stages  of  croupous  pneumonia  may  be 
studied  both  with  the  screen  and  the  skiagram.  A  central  pneumonia 
which  resists  detection  by  the  ordinary  physical  signs  may  be  detected 
by  the  aid  of  the  X-rays. 

In  the  stage  of  congestion  there  is  a  uniform  dark  shadow  cast  on  the 
fluorescent  screen  ;  the  result  of  an  increased  quantity  of  blood  in  the 
affected  part  of  the  lung. 

The  stage  of  consolidation  presents  a  still  darker  shadow,  due  to  the 
increased  density. 

A  centralized  consolidation,  not  demonstrable  clinically,  throws  a 
shadow  on  the  screen,  equally  as  well  as  a  simple  superficial  lesion.  In 
croupous  pneumonia  I  have  observed  the  middle  lobe  of  the  right  lung 
to  be  the  one  most  frequently  involved.  In  this  condition  the  excursions 
of  the  diaphragm  are  almost  entirely  obliterated.  In  the  majority  of  in- 
stances the  right  side  of  the  heart  is  enlarged  and  displaced  to  a  greater 
or  less  extent.  In  some  cases  involvement  is  so  extensive  as  to  shroud 
the  shadow  ordinarily  cast  by  the  heart.  That  the  cardiac  displacement 
is  due  to  the  pressure  of  the  dense  lung,  is  demonstrable  by  the  rays. 

The  stage  of  resolution  is  characterized  by  the  lung  tissue  returning 
to  its  former  normal  structure,  and  when  the  shadow  cast  by  the  pre- 
viously affected  side  is  similar  to  that  cast  by  the  non-involved  side,  we 
speak  of  the  organ  as  having  again  returned  to  the  normal.  The 
shadow  of  the  previously  affected  area  may  persist  until  complete  reso- 
lution has  occurred,  while  continued  persistence  of  a  shadow  in  this 
region  may  indicate  a  thickened  pleura. 

A  croupous  pneumonia  must  be  diagnosticated  from  pleurisy  with 
effusion,  from  an  acute  bronchitis,  and  from  pulmonary  tuberculosis. 
The  physical  signs  and  clinical  symptoms  are  frequently  ill-defined  in  a 
pleurisy  with  effusion,  so  that  it  may  be  confounded  with  a  pneumonia. 
In  a  non-encysted  pleurisy  with  effusion,  a  dark  shadow  is  thrown  on 
the  screen,  which  changes  its  position  with  the  change  of  position  of  the 
patient.  In  a  pneumonia  there  is  no  change  in  the  shadow  demonstrable 
when  moving  the  patient.  In  pleurisy  with  effusion  there  is  a  much 
greater  displacement  of  the  heart  than  in  an  uncomplicated  pneumonia. 

Lately  I  examined  a  child  for  an  unresolved  pneumonia,  affecting  the 
middle  lobe  of  the  right  lung.  The  consolidated  spots  closely  simulated 
a  dry  pleurisy  ;  but  the  latter  casts  an  irregular  longitudinal  shadow,  the 
former  circular. 

Atelectasis. — The  shadows  produced  correspond  to  the  areas  involved 
in  the  collapse  of  the  lung.  If  collapse  is  extensive,  the  shadows  cast  on 
the  screen  are  corresponding  in  size.  The  excursions  of  the  diaphragm 
are  not,  as  a  rule,  restricted,  and  its  position  is  normal.  The  heart 
does  not  change  in  its  normal  shape,  size,  and  position  in  a  beginning 


APPLICATION  OF  THE  X-EAYS.  321 

atelectasis,  though  in  advanced  cases  with  fibrous  tissue  formation,  fol- 
lowed by  contraction  of  large  parts  of  lung  tissue,  the  heart  may  finally 
be  more  or  less  displaced.  The  shadows  may  disappear  if  the  patient  is 
instructed  to  breathe  as  forcibly  as  he  can. 

Abscess  and  Gangrene. — The  exact  location  of  either  an  abscess  or 
gangrene  is  indicated  by  a  dark  shadow.  These  conditions  are  usually 
found  to  involve  the  lower  part  of  the  middle  lobe  or  upper  part  of  the 
lower  lobe.  As  an  abscess  cavity  usually  opens  internally,  and  the  foul 
material  is  expectorated,  the  shadows  disappear  immediately  after  the 
cavity  is  emptied.  The  excursions  of  the  diaphragm  are  usually  more  or 
less  restricted,  depending  upon  the  size  and  location  of  the  abscess.  The 
position  of  the  diaphragm  is  normal,  and  the  heart  does  not  change  in 
position.  If  the  shadows  are  multiple,  they  indicate  multiple  abscesses. 

B.  DISEASES  OF  THE  PLEURA. 

Pleurisy  with  Effusion. — In  pleurisy  with  effusion  the  diaphragm  is 
only  slightly,  if  at  all,  observed  on  the  screen,  depending  upon  the 
amount  of  the  effusion  present.  Because  of  the  pressure  exerted  by  the 
ilu id  upon  the  adjacent  lung  tissue,  the  latter  is  more  dense  ;  hence  the 
fluid  throws  a  dark  shadow  upon  the  fluorescent  screen,  usually  denser 
than  that  cast  in  any  other  thoracic  condition. 

On  changing  the  position  of  the  patient,  the  change  of  level  is  easily 
discerned  by  the  aid  of  the  fluorescent  screen.  The  upper  level  of  the 
fluid  is  better  seen  in  the  sitting  than  in  the  recumbent  posture.  With 
an  abundant  quantity  of  fluid  within  the  pleura!  sac,  the  heart  as  a 
rule  suffers  considerable  displacement,  and  far  greater  when  the 
pleural  effusion  is  confined  to  the  left  side  than  when  it  exists  on  the 
right  side  only. 

The  shadows  of  the  ribs  are  usually  very  faintly  shown  on  the  affected 
side  above  the  pleural  effusion.  As  a  rule,  the  heart  is  displaced  prior 
to  a  downward  displacement  of  the  diaphragm.  The  excursions  of  the 
diaphragm  are  usually  much  restricted,  especially  when  the  effusion  is 
abundant.  Small  effusions  are  often  to  be  detected  in  the  small  angular 
spaces  on  each  side  between  the  diaphragm  and  chest  wall.  Pleural 
thickenings  are  not  infrequently  mistaken  for  small  effusions.  Pleural 
adhesions  are  indicated  by  limited  excursions  of  the  diaphragm.  After 
aspiration  a  clearing  up  of  the  previous  darkened  shadow  may  be 
noted,  the  ribs  may  again  be  detected,  the  heart  will  immediately  re- 
sume its  normal  position,  and  the  excursions  of  the  diaphragm  are  again 
increased. 

Even  though  there  is  only  a  small  quantity  of  effusion  in  the  pleural 
sac,  the  lung  tissue  above  the  fluid  level  toward  the  apex  presents  a 
darker  appearance  than  the  same  field  of  the  normal  side,  this  being  in 
all  probability  due  to  a  compression  of  the  lung  on  the  affected  side.  If 

21 


322  ELECTRO-THERAPEUTICS. 

the  right  pleural  sac  is  completely  filled  by  fluid,  this  shadow  fuses  with 
that  of  the  heart  (in  the  mediau  line  or  slightly  to  the  right),  liver,  and 
diaphragm  ;  hence,  all  the  brightness  of  the  right  side  is  totally  lost. 

Prof.  Ch.  Bouchard l  was  the  first  investigator  to  publish  observations 
made  with  the  screen  in  pleural  effusions.  He  demonstrated  that  the 
X-rays  do  not  pass  through  the  effusion.  He  also  showed  that  the  shadow 
indicated  the  upper  level  of  the  fluid,  as  confirmed  by  the  ordinary 
methods  of  physical  diagnosis. 

Dally,2  from  his  radioscopic  study  of  pleurisy  with  effusion,  concludes 
that  the  level  of  the  fluid  changes  with  the  position  of  the  patient  unless 
the  quantity  of  fluid  is  great  and  is  encysted  by  adhesions.  A  puru- 
lent effusion  yields  a  shadow  of  greater  density  than  a  sero-fibrinous 
effusion.  The  shadow  is  homogeneous,  and  in  the  case  of  the  serous 
effusion  the  shadow  gradually  increases  in  density  from  above  downward. 
However  far  the  heart  is  displaced  to  the  right,  in  most  cases  little 
alteration  takes  place  in  the  position  of  the  apex  relatively  to  the  base. 
Other  conditions  being  equal,  the  heart  is  displaced  more  when  the 
effusion  is  left  sided.  A  somewhat  triangular  shadow,  not  normally 
visible,  above  and  continuous  with  the  shadow  of  the  heart  and  pericar- 
dium is  cast  by  the  mediastinum,  which  is  displaced  by  the  lateral 
pressure  towards  the  healthy  side  of  the  thorax. 

Empyema. — In  empyema  the  displacement  of  the  heart  and  liver  is 
greater  than  with  the  same  quantity  of  serous  exudate.  In  pulsating 
pleurisy,  the  heart  movements  transmitted  to  the  fluid  may  be  seen  as 
diffuse  undulations,  if  the  patient  remains  motionless  for  the  time  being. 
According  to  my  experience,  the  shadow  of  an  empyema  on  a  fluorescent 
screen  frequently  seems  to  be  a  shade  darker  than  that  produced  in  an 
ordinary  pleurisy  with  effusion.  This  may  be  accounted  for  by  the  fact 
that  in  an  empyema  there  is  usually  associated  a  slight  redema  of  the 
chest  wall  over  the  seat  of  the  exudate.  When  there  is  no  such  cedema- 
tous  condition  coexisting  with  an  empyema,  the  shadow  cast  by  the 
retained  pus  is  of  the  same  density  as  that  of  an  ordinary  pleural  effu- 
sion. An  interlobar  empyema  (a  condition  very  difficult  to  diagnosti- 
cate by  ordinary  means)  casts  a  shadow  of  the  encysted  pus  on  the  screen; 
the  surrounding  lung,  above  and  below,  presents  the  normal  brightness, 
provided  there  is  little  or  no  compression  of  the  adjacent  pulmonary 
tissue  by  the  enclosed  fluid,  the  movements  of  the  diaphragm  are  not 
restricted,  nor  is  the  heart  displaced  from  its  normal  position.  Dia- 
phragmatic pleurisy  is  indicative  of  an  involvement  of  the  pleura  in 
relation  to  the  diaphragm.  There  is  usually  a  small  quantity  of  exu- 
date present,  which  can  only  be  revealed  with  difficulty,  by  a  careful 
screen  examination.  Of  several  cases  of  this  condition  that  came  to  my 

1  Archives  d'£lect.  M&iicale,  July  13,  1896. 

2  Lancet,  February  27,  1904. 


APPLICATION  OF  THE  X-RAYS.  323 

attention,  four  showed  very  distinct  shadows  on  the  screen.  Hemor- 
rhagic  pleurisy  cannot  easily  be  differentiated  from  other  types  of 
pleurisy  by  the  X-rays. 

A  pleurisy  of  the  sac  with  effusion  may  be  complicated  with  an 
empyema.  An  einpyeinatous  condition  of  the  left  pleura  would  make  its 
appearance  on  the  opposite  side.  In  case  a  pleurisy  has  been  disgnosti- 
cated,  complicated  by  unusual  dyspnoea,  the  examiner  should  then  look 
for  an  associated  empyema  of  the  opposite  lung. 

Pneumothorajc.  —  The  affected  side  presents  a  very  bright  area  and 
of  rather  large  size.  The  lung  tissue  is  retracted,  and  the  diaphragm 
occupies  a  lower  position  than  normal ;  its  movements  are  greatly  re- 
stricted, and  occasionally  no  movements  are  at  all  recognizable.  The 
cardiac  outlines  are  clearly  defined,  with  a  displacement  toward  the 
unaffected  side. 

Hydro-pneumothorajc  and  Pyo-pneumothorax. — In  studying  the  affected 
side  of  the  chest,  with  the  patient  in  the  sitting  posture,  the  fluorescent 
screen  shows  a  very  dark  area  below  and  a  lighter  one  above.  It  is  best 
demonstrated  with  the  tube  behind  the  patient,  the  target  facing  the 
third  intercostal  space  (fourth  rib).  With  the  change  of  position  of 
the  patient,  the  fluid  may  be  noticed  to  alter  its  level ;  the  fluid  also 
changes  its  level  during  respiration,  rising  during  a  deep  inspiration  and 
falling  during  a  deep  expiration. 

The  excursions  of  the  diaphragm  are  usually  wholly  obliterated, 
while  it  also  occupies  a  very  low  position,  and  the  heart  is  displaced 
toward  the  unaffected  side.  The  pulsations  disturb  the  upper  level  of 
the  fluid  area,  a  condition  which  may  be  readily  studied  by  the  fluores- 
cent screen.  If  the  lung  is  examined  in  the  median  line  and  above  the 
fluid  area,  it  usually  appears  slightly  darker  as  a  result  of  compression. 
The  degree  of  displacement  of  the  heart  and  liver  depends  upon  the 
amount  of  air  and  fluid  retained  in  the  pleura!  cavity.  An  apical  tuber- 
culosis of  the  affected  side  can  very  readily  be  diagnosed,  as  the 
surrounding  field  usually  appears  intensely  bright. 

Subplurnic  Abscess. — A  subphrenic  abscess  gives  a  dark  shadow  in 
the  lower  part  of  the  thorax,  and  above  it  there  is  a  lighter  shadow  due 
to  the  presence  of  air.  and,  surmounting  this,  there  will  be  a  shaded  field 
caused  by  the  compressed  lung.  The  diaphragm  occupies  a  slightly 
higher  position  with  a  total  abolition  of  its  movements.  The  heart  is 
displaced  toward  the  unaffected  side,  though  this  displacement  is  not  so 
extensive  as  in  hydro-pneumothorax.  The  upper  level  of  the  dark  area 
changes  with  the  change  of  position  of  the  patient,  and  splashing  of  the 
enclosed  fluid  may  be  recognized  when  the  patient  is  grasped  by  the 
shoulders  and  shaken. 

Tumors  of  the  Thorax. — Intrathoracic  growths  cast  shadows  upon  the 
fluorescent  screen.  These  masses  are  generally  circumscribed,  and  are,  as 
a  rule,  located  in  the  upper  part  of  the  chest.  Care  must  be  exercised  to 


324  ELECTRO-THERAPEUTICS. 

differentiate  these  growths  from  thoracic  aneurism  ;  in  the  former  the 
tumor  pulsates  with  an  up  and  down  movement,  in  the  latter,  the  move- 
ment is  expansile. 

If  the  tumor  is  not  too  large  there  is  no  restriction  in  the  excursions 
of  the  diaphragm.  The  heart  is  generally  slightly  displaced.  Small 
calcified  lymphatic  and  bronchial  glands  are  often  noticeable. 

Enlarged  Glands. — Any  enlargement  of  the  thoracic,  mediastiual,  or 
bronchial  glands  is  easily  shown  on  the  fluorescent  screen  or  skiagraph. 
As  the  bronchial  glands  are  usually  first  involved  in  tuberculous  condi- 
tions of  the  lungs,  a  few  authorities  have  successfully  demonstrated  a 
slight  enlargement  of  the  glands  in  the  incipient  stage.  Any  glandular 
enlargement  should  be  viewed  suspiciously  as  the  beginning  of  an  adja- 
cent tuberculous  involvement,  This  condition  is  best  viewed  on  the 
screen  by  having  the  rays  traverse  the  body  diagonally. 

IV.   Application  of  the  X-rays  to  the  Circulatory  System. 

In  fluoroscoping  the  normal  heart  in  the  anterior  view,  we  observe 
the  shadow  of  the  heart  and  aorta.  These  shadows  are  due  to  the  opacity 
of  the  contained  blood  and  to  the  superimposed  shadows  of  the  verte- 
brae and  sternum.  The  posterior  view  shows  the  same  structures  in  their 
posterior  aspects.  The  anterior  view,  however,  is  preferable,  as  the  heart 
being  nearer  the  chest  wall  allows  of  a  clearer  shadow  on  the  fluoroscope. 
Fluoroscopy  is  preferable  to  skiagraphy  in  the  study  of  the  circulatory 
system,  as  with  it  we  can  observe  the  cardiac  cycle,  the  aorta  and  the 
movements  of  the  diaphragm,  from  various  positions. 

A.  FLUOROSCOPIC  EXAMINATION  OF  THE  NORMAL  HEART. 

The  heart  may  be  examined  with  the  patient  in  the  sitting,  standing, 
or  recumbent  posture.  The  heart  when  viewed  by  the  screen  occupies  a 
characteristic  position  in  the  thorax,  when  the  patient  is  seated  on  a  stool. 
During  expiration  it  rests  on  the  diaphragm,  its  long  axis  forming  an 
acute  angle  with  the  imaginary  median  line  of  the  thoracic  cavity.  In 
inspiration  the  heart  moves  downward  and  toward  the  median  line  ;  the 
right  border  of  this  organ  is  plainly  seen  to  the  right  of  the  sternum,  the 
larger  or  left  part  of  the  heart  is  seen  to  the  left  of  the  sternum, — i.e., 
the  long  axis  of  the  heart  forms  with  the  median  line  during  expiration 
a  less  acute  angle  than  during  an  inspiratory  effort.  During  inspiration 
the  transverse  diameter  of  the  heart  is  slightly  decreased  in  length,  at 
the  same  time  the  number  of  pulsations  are  lessened.  In  expiration, 
after  the  diaphragm  has  discontinued  tugging  on  the  heart,  the  transverse 
diameter  is  again  increased,  as  is  also  the  amplitude  of  its  pulsations. 
The  general  contour  of  the  organ  can  be  more  easily  seen  during  inspira- 
tory periods  than  in  the  expiratory,  because  the  lungs,  being  filled  to  their 
capacity,  are  more  transparent  to  the  rays,  thus  offering  a  more  striking 


APPLICATION  OF  THE  X-RAYS.  325 

contrast.  The  cardiac  outline  may  be  readily  differentiated  by  means  of 
the  ingenious  artifice  of  Dr.  Disan.1  By  this  method  the  outline  of  a 
normal  heart  is  traced  on  the  chest  by  fixing  with  adhesive  strips  a  copper 
wire.  A  iluoroscopic  examination  is  then  made  in  the  following  way  : 
At  first  the  greatest  strength  of  current  obtainable  from  the  apparatus 
is  turned  on.  The  observer  looks  through  the  fluoroscope  and  gets  the 
chief  landmarks  of  the  chest,  such  as  the  scapula,  ribs,  spine,  diaphragm, 
and  upper  convex  border  of  the  liver,  the  wire  being  at  the  same  time  in 
full  view.  The  current  is  now  reduced  until  the  heart  becomes  more  dis- 
tinctly visible.  The  fluoroscope  is  applied  to  a  spot  marked  at  the  left 
of  the  spine,  corresponding  to  the  fourth  intercostal  space  in  front  of  the 
chest.  Any  alterations  in  the  shape  of  the  heart  can  thus  be  easily 
demonstrated. 

The  shadows  of  the  pulmonary  vessel  and  in  many  instances  the  vena 
cavii!  can  be  recognized  if  the  chest  is  made  to  assume  a  position  diagonal 
or  oblique  to  the  screen  and  tube. 

The  pulsations  of  the  heart  are  less  in  number  during  a  deep  inspira- 
tion than  in  expiration,  or  even  in  the  ordinary  quiet  breathing.  These 
pulsations  are  lessened  during  a  deep  inspiration  and  by  increase  of  the 
air  pressure  upon  the  heart, — i.  e.,  the  pressure  from  the  pericardium, 
which  is  made  more  taut  during  the  descent  of  the  diaphragm. 

The  Orthodiayraph. — This  instrument  was  devised  by  F.  Moritz,  of 
Munich.2  (Figs.  179  and  180.)  Its  purpose  is  the  bringing  out  of  any 
object  in  its  exact  size  and  without  distortion.  By  it  the  size  and  shape 
of  all  the  recognizable  internal  organs,  as  well  as  other  parts  of  the  body, 
can  be  determined.  As  the  Rontgen  rays  are  propagated  from  a  point 
on  the  anodal  field  in  straight  lines  radiating  in  every  direction,  and  as 
the  image  of  a  body  projected  on  a  phosphorescent  screen  or  skiagram  is 
a  silhouette,  the  outline  of  the  object  presented  coincides  with  the  places 
where  the  rays  coming  in  contact  with  the  edge  of  the  body  impinged 
upon  the  screen.  This  outline,  therefore,  is  the  periphery  of  the  base 
of  a  cone,  whose  point  coincides  with  the  luminous  spot  of  the  anti- 
cathode.  As  the  object  to  be  projected  is  located  between  the  vacuum 
tube  and  the  screen,  the  image  on  the  latter  will  be  magnified,  the  degree 
of  magnification  being  dependent  upon  the  ratio  of  the  distance  of  the 
object  from  the  image  plane  and  the  distance  of  the  object  from  the 
vacuum  tube.  The  image  projected  by  a  vacuum  tube,  so  far  from  re- 
cording the  true  dimensions  and  shape  of  the  object,  will  show  the  latter 
more  or  less  magnified  and  distorted.  In  order  to  obtain  the  true  shape 
and  size  of  the  object,  the  rays  touching  the  body  and  forming  on  the 
plate  an  image  of  its  outlines  must  be  made  parallel  and  strike  the 
plate  at  right  angles, — i.e.,  the  projection  from  a  centre  must  be 

1  Dominion  Medical  Monthly,  February,  1897. 

2  Berlin  Allgenieine  Electricitats  Gesellschaft,  and  Munch,  ined.  Wochenschrift, 
April  10,  1900. 


326  ELECTRO-THERAPEUTICS. 

replaced  by  a  projection  that  is  parallel.  "SVith  the  orthodiagraph,  pro- 
jections true  in  shape  and  size  are  obtained  in  any  desired  position  of 
the  drawing-plane. 

The  luminous  screen  which  also  carries  the  drawing  stylus  is  con- 
nected with  the  Eontgen  tube  by  a  U-shaped  fi-ame.  This  frame,  made 
up  of  a  number  of  jointed  sections,  permits  of  any  desired  adjustment  of 
the  screen  with  the  tube.  A  rod  extending  from  the  screen  is  longi- 
tudinally adjustable  in  a  split  sleeve  on  the  end  of  a  tube  lying  parallel 
with  the  axis  of  the  drawing  stylus.  The  tube  is  provided  with  a  tele- 
scoping member,  on  the  projecting  end  of  which  a  second  split  sleeve  is 
adapted  to  slide.  This  screen  is  formed  on  the  end  of  an  arm  which  is 
thereby  supported  at  right  angles  to  the  telescoping  member.  The  clamp 
holding  the  tube  has  a  ball-and-socket  connection  with  a  member  which 
may  be  adjusted  to  any  position  along  the  arm.  When  properly  adjusted 
the  propagating  joint  of  the  X-rays  should  lie  on  an  extension  of  the  axis 
of  the  stylus.  This  may  be  done  approximately  by  adjusting  the  tube 
clamp  and  other  members  of  the  U-shaped  frame.  In  order  to  obtain  a 
more  perfect  adjustment  of  the  tube, — i.  e.,  such  adjustment  as  would  per- 
mit working  with  accurate  perpendicular  rays, — the  screen  may  be  ad- 
justed in  one  plane,  by  moving  its  supporting  rod  longitudinally  in  the 
split  sleeve  above  referred  to,  and  in  a  plane  at  right  angles  thereto,  by 
adjustment  of  the  screen  within  its  holder.  By  noting  the  shadow  cast 
on  the  screen  by  the  end  of  the  stylus  projecting  there  through,  the  oper- 
ator can  readily  ascertain  when  accurate  adjustment  has  been  obtained. 

Parallel  movement  of  the  tube  with  the  screen  is  obtained  by  means 
of  two  levers,  one  pivoted  to  the  other.  A  lever  which  supports  at  one 
end  the  U-shaped  frame  is  hinged  to  a  second  lever,  which  in  turn  is  piv- 
oted to  a  bracket  on  the  end  of  the  supporting  column  of  the  apparatus. 
Each  lever  is  provided  with  a  counter- weight,  movable  along  its  outer 
arm,  and  these  weights  serve  to  hold  the  parts  in  equilibrium. 

The  bracket  just  mentioned  also  carries  a  rod,  to  which  the  drawing 
frame  is  attached  by  means  of  a  universal  joint.  The  drawing  frame  is 
adapted  to  be  covered  with  heavy  bristol- board,  held  therein  by  holders 
at  the  sides,  and  on  this  surface  the  drawing  stylus  is  softly  pressed  by  a 
spiral  spring. 

Now  the  whole  system  so  far  described  is  movable  around  the  axis 
in  the  head  of  the  main  supporting  column,  and  may  be  clamped  in  any 
position  by  means  of  a  milled  nut;  an  additional  fixing  lever  may  l>e 
grasped  to  prevent  this  system  from  suddenly  dropping  or  loosening  the 
nut.  At  the  same  time,  the  accurately  vertical  and  horizontal  position 
of  the  system  is  indicated  by  a  spring  catch.  The  length  of  the  support- 
ing column  is  such  that  on  turning  the  system  round  its  axis  into  a  hori- 
zontal position,  the  drawing  plate  will  just  be  at  a  convenient  distance 
above  a  person  lying  on  an  ordinary  table  of  about  30  inches  in  height. 
The  heavy  base  plate  is  provided  with  four  rollers  allowing  of  the 


APPLICATION  OF  THE  X-EAYS. 


327 


drawing  apparatus  being  readily  moved.  By  operating  special  screws, 
these  rollers  may  l>e  removed,  and  the  apparatus  placed  on  the  points 
of  the  screws,  which  in  addition  will  allow  of  the  column  of  the 
apparatus  being  given  an  accurately  vertical  position  even  on  oblique  or 
uneven  floors. 

When  a  drawing  is  to  be  made  directly  on  the  body,  the  bristol-board 
is  removed  from  the  drawing  frame,  and  a  dermatograph  stylus  should 
be  inserted  into  the  drawing  stylus,  instead  of  a  pencil.  The  drawing 


FIG.  181.— Levy-Dorn's  orthodiagraph  for  the  standing  position. 

frame  is  provided  with  three  pencil-holders,  or  ''plotters,"  as  they  are 
called,  which  are  movable  in  the  plane  of  the  screen  or  in  that  of  the 
drawing  plate,  and  provided  with  scales  in  both  co-ordinates ;  the  posi- 
tion of  a  person  with  regard  to  the  central  ray  may  be  thereby  ascertained, 
so  that  on  the  examination  being  repeated  the  same  position  of  the  per- 
son may  be  accurately  secured.  A  fourth  auxiliary  plotter  has  been  pro- 
vided with  slides  on  a  scale  projecting  from  the  extended  axis  of  the 
lower  supporting  lever. 


328 


ELECTRO-THERAPEUTICS. 


In  addition  to  reproducing  the  true  shape  and  size  of  organs,  the 
apparatus  may  be  advantageously  used  to  ascertain  the  depth  of  foreign 
objects.  This  can  be  done  by  measuring  the  apparent  diameter  of  the 
object  when  the  Rontgen  tube  is  stationary,  and  then  ascertaining  the 
actual  shape  of  the  body  by  means  of  parallel  movement  of  the  drawing 


Reimger,Gebberh  BtSchall,  Erlangen. 
FIG.  182.— Levy-Doru's  orthodiagraph  for  use  in  the  recumbent  posture. 

stylus  and  the  tube.  Xow  if  a  I  is  the  apparent  length  of  a  foreign  body. 
r  I  its  real  length,  D  the  distance  of  the  anticathode  of  the  tube  from  the 
luminous  screen,  and  d  the  distance  of  the  object  from  the  anticathode, 

the  formula  -  -  will  give  the  true  distance  of  the  foreign  b<><ly 

from  the  luminous  screen. 

The  Levy-Dorn  orthodiagraph  is  shown  in  Figs.  181  and  182.  The 
advantage  of  this  instrument  lies  in  the  fact  that  during  the  examina- 
tion of  the  heart  the  operator  measures  the  vertical  and  horizontal  axes 
on  the  scales. 

B.  SKIAGRAPHIC  EXAMINATION  OF  THE  HEART. 

The  heart  can  be  skiagraphed  with  the  same  technic  as  is  applicable 
to  the  lung,  but  the  former  requires  more  precision  in  the  position  of  the 
patient,  tube,  distance,  etc.  The  patient  may  be  seated  on  a  chair  and 
the  plate  placed  either  over  the  chest  (sternum),  in  the  anterior  or 


c  S 


c  "3 


C  3 

E  « 

c  5 

PL.  * 

fc  "3 


APPLICATION  OF  Till-}  X-KAYS.  329 

ventral  view,  or  to  the  back  (posterior  view).  Ask  the  patient  to  raise 
both  arms,  in  order  to  remove  the  shadows  of  the  scapula?  from  the 
thorax.  Centre  the  anode  of  the  Crookes  tube  over  the  level  of  the  third 
rib  in  back  and  one  inch  below  the  upper  end  of  the  sternum  in  the 
median  line.  The  distance  of  the  anode  from  the  plate  should  be  from 
25  to  30  inches  <;:>-::>  c-m.X  An  anterior  and  posterior  skiagraph  should 
be  made  at  the  same  time,  noting  that  no  abnormality  or  deformity 
exists.  If  the  tube  is  placed  in  an  oblique  position  the  shadows  will  often 
mislead  and  confuse.  Anterior  and  posterior  oblique  (right  and  left) 
skiagraphs  should  also  be  taken,  in  order  to  study  mediastinal  tumors, 
and  the  arch  of  the  aorta.  The  time  of  exposure  should  be  as  short 
as  possible,  correspondingly  to  the  cardiac  cycle.  Two  methods  of 
skiagraphing  the  thorax  are  presented  in  Figs.  183  and  184. 

M.  (hiilleminot,  of  Paris,  invented  an  instrument  by  which  he  can 
make  cinemato-radiographic  pictures.  The  exposures  can  be  made  either 
during  inspiration,  expiration,  or  during  the  ascent  and  descent  of  the 
diaphragm  ;  and  also  during  the  systole  and  diastole  of  the  auricles  and 
ventricles.  I  have  made  stereo-skiagrams  of  the  thoracic  organs  of 
young  thin  subjects,  which  have  yielded  for  scientific  study  the  true 
perspective  and  relief  effects  of  the  heart,  aorta,  sternum,  and  vertebrae  ; 
such  results  are  of  clinical  worth  in  studying  aneurisms  and  cavitations. 

Size  and  J/m.s-///v///o//  of  th<-  Heart. — According  to  Abrams,1  with  the 
screen  at  about  29;  inches  (75  cm.)  from  the  tube  and  with  the  target 
directed  toward  a  point  where  the  median  line  is  crossed  by  the  fourth 
ril>,  the  normal  heart  is  seen  to  extend  from  the  median  line  1T\  inches 
(3  cm.)  on  the  right  side  and  3y^  inches  (8.5  cm.)  on  the  left  side,  the 
total  width  of  the  heart  being  about  4  inches  (or  10  cm.). 

MobiJitii  of  the  Jlcart.  — Silbergleit*  describes  a  case  in  which  the 
entire  heart  was  capable  of  lateral  displacement  of  several  inches  by  a 
change  from  the  left  lateral  to  the  right  lateral  position.  The  patient 
was  a  man  of  twenty-four  years  who  came  under  observation  for  gastro- 
enteritis and  a  moderate  degree  of  chlorosis.  He  had  no  subjective 
symptoms  referable  to  the  heart,  and  in  the  standing  position  or  when 
lying  on  the  back  physical  examination  of  the  organ  was  negative. 
When  lying  on  the  left  side,  however,  the  apex  beat  was  three  centi- 
metres outside  of  the  mammary  line,  and  the  right  border  one  centimetre 
to  the  left  of  the  left  sternal  margin.  When  on  the  right  side,  the  apex 
beat  appeared  close  to  the  left  sternal  margin  and  the  right  border  was 
correspondingly  displaced.  This  case  is  of  scientific  value,  in  that  the 
abnormal  mobility  is  only  an  index  of  an  existing  cardiac  lesion. 

Sears3  states  that  Determann's  experiments,  made  with  the  X-rays 
and  by  percussion,  demonstrated  the  mobility  of  the  heart  with  change 

'Journal  of  the  American  Medical  Association,  May  3,  1902. 

M.-.li.-.il  Kro.nl,  June  20,  1903. 

M.  .ii.al  Standard,  January  1,  1901. 


330 


Ea^ECTBO-THBBAPBUTICS. 


of  position.  lu  the  healthy  individual  turning  on  the  left  side  produced 
an  average  displacement  of  2'  centimetres  to  the  left  and  1  centimetre 
upward  ;  turning  on  the  right  side  occasioned  a  change  of  1J  centimetres 
to  the  right  and  about  £  centimetre  upward.  In  some  cases  the  displace- 
ment was  quite  small,  in  others  as  much  as  6^  centimetres  to  the  left  and 
4  centimetres  to  the  right,  without  distress  to  the  subject.  These  greater 
movements  were  found  to  occur,  as  a  rule,  in  flabby  and  ill -nourished 
individuals  and  in  those  whose  abdominal  organs  were  loosely  anchored. 
It  was  observed  that  women  usually  have  more  freely  movable  hearts 
than  men,  especially  after  childbearing  or  from  the  use  of  tight  slays. 
Children  have  little  signs  of  it,  the  newborn  scarcely  any,  and  in  old 
persons  it  is  slight.  Individuals  of  sedentary  habit  and  feeble  muscular 
development  are  especially  subject  to  the  condition.  The  physiological 
effect  of  the  full  stomach  is  noted,  and  also  anything  which  tends  to 
elevate  the  diaphragm.  During  the  latter  part  of  pregnancy  the  heart  is 
much  pushed  up  and  is  compressed,  thus  showing  very  little  mobility. 
Immediately  after  delivery,  however,  the  highest  grade  is  found,  and  the 
apex  may  be  displaced  on  the  left  side  9  centimetres  from  its  original 

position. 

MORITZ  TABLE.1 

Healthy  Adult  Man  (Age  17  to  56). 


J3    ° 

Si  2 

=  5 

•  I 

1 

2 

2  13 

£  a 

9 

HEIGHT  OF  THE 
PERSON 

DIMENSIONS 

~  = 

I  1 

S 

I  ± 

5  g 

1 

i  .2  *-• 

a 

S  a 

i  "5  "3> 

S    *  "o 

be 

S  ~ 

5S2 

i  ^  — 

a 

Q 

gp 

5 

cm. 

cm. 

cm. 

cm. 

cm. 

153-157  cm.  or 

average 

4.4 

7.9 

13.0 

10.2 

98 

6  ft.    9   inches 

maximum 

4.S 

s.o 

13.5 

10.5 

100 

5  ft.  10i  inches 

minimum 

4.0 

7.8 

11.6 

10.0 

SO 

161-169  cm.  or 

average 

4.4 

8.8 

13.4 

10.5 

102 

6  ft.  0    inches 

maximum 

5.0 

9.8 

14.5 

10.8 

108 

6  ft.  3^  inches 

minimum 

3.5 

7.5 

12.8 

9.0 

87 

171-178  cm.  or 

average 

4.6 

8.8 

14.0 

10.3 

100 

6  ft.    4  inches 

maximum 

5.9 

9.7 

16.8 

11.0 

126 

6  ft.  7J  inches 

minimum 

3.0 

7.8 

1L>.5 

9.0 

92 

Displacement. — In  this  condition  the  heart  may  retain  its  normal 
shape,  only  changing  its  position.  The  most  frequent  cardiac  displace- 
ment is  dextro-cardia,  which  is  a  congenital  malposition.  In  the  acquired 


ML   Gocht,  "Ilandbuch 
(von  17  bis  56  Jahren)." 


der    Rontgenlehre,"  "  Erwaohsene   gesunde    Manner 


APPLICATION  OF  TILE  X-IiAYS.  331 

forms  of  malposition  the  heart  may  be  displaced  low  down  in  the  chest, 
the  pulsations  may  be  felt  behind  and  below  the  lowermost  extremity  of 
the  sternum,  or  it  may  be  placed  to  the  right  of  the  sternum  or  the  left 
outside  the  left  nipple  line,  these  facts  being  confirmed  at  the  same  mo- 
ment with  the  fluoroscope.  Fluid  in  the  left  pleural  sac  causes  the  heart 
to  be  pushed  toward  the  right  side,  while  exactly  the  opposite  condition 
exists  when  the  right  pleural  cavity  is  so  affected  ;  but  in  dry  pleurisy  the 
adhesions  may  draw  the  heart  toward  the  affected  side.  Disteution  of 
the  pleural  cavity  by  gas,  as  seen  in  emphysema,  also  causes  a  displace- 
ment either  to  the  right  or  the  left,  depending  upon  the  cavity  that  is 
involved.  An  increased  elevation  of  the  diaphragm  causes  the  heart  to 
assume  a  position  on  its  long  axis  so  that  the  right  ventricle  is  pulled  to 
the  anterior  position,  the  chief  feature  of  recognition  being  the  increased 
distinctness  of  the  right  side  of  the  heart  when  the  chest  is  examined  from 
behind. 

Cardiac  Atrophy,  Hypertrophy,  and  Dilatation. — These  conditions  are 
revealed  by  a  screen  examination.  Atrophy  presents  a  small  size  of  the 
organ.  In  hypertrophy  or  dilatation  of  the  left  ventricle,  the  apex  has 
changed  from  its  normal  position,  the  shadow  area  is  increased,  and  the 
clear  space  normally  existing  between  the  heart  and  liver  (as  seen  on  a 
deep  inspiration)  is  diminished  in  size  or  has  totally  disappeared.  If  the 
right  ventricle  is  increased  in  size  the  base  usually  appears  more  or  less 
drawn  down  and  the  long  axis  assumes  a  more  nearly  horizontal  position. 
Abdominal  distentiou,  with  either  fluid  or  gas,  causes  an  elevation  of  the 
diaphragm,  hence  another  cause  for  change  in  the  position  of  the  heart. 
I  have  often  noticed  that  the  heart  atrophies  in  advanced  cases  of  tuber- 
culosis. In  a  pneumonia,  displacement  is  usually  toward  the  unaffected 
side ;  in  an  extensive  emphysema  the  heart  naturally  occupies  a  posi- 
tion lower  than  normal.  Aneurisms,  new  growths,  and  adhesions  are 
aiming  the  other  causes  of  cardiac  displacement.  Thome1  observed  a 
heart  to  shrink  after  its  exposure  to  the  Kontgen  rays  for  thirty  minutes. 
In  one  case,  the  heart  had  shrunken  in  its  long  axis  some  1J  to  2  inches 
(  4..">  to  5  cm.),  while  in  its  transverse  diameter  the  contraction  amounted 
to  li  inches  (4cm.).  Experiments  in  this  connection  have  been  con- 
ducted on  dogs,  the  results  in  general  showing  a  considerable  shrinking. 

Care  should  be  taken  when  fluoroscoping  the  heart  to  differentiate 
between  true  atrophy  and  displacement.  In  the  Schott  treatment  of 
lu'art  disease,  the  attendant  studies  the  patient's  heart  before  and  after 
each  treatment.  I  have  never  observed  any  change  in  the  size  of  the 
heart  except  an  alteration  in  the  pulse  rate  noted  in  certain  neurotic  cases. 

Acute  Dilatation  of  Heart. — F.  Moritz2  stated  that  orthodiagraphy  has 
failed  to  confirm  the  occurrence  of  any  appreciable  acute  dilatation  after 

'British  Medical  Journal,  1896,  vol.  ii.  p.  1238. 

2Miinchener  medicinist-he  Worhensrhrift.  Hi..  N».  !•">.  April  11:  "  Acute  dilatation 
of  the  heart  due  to  diphtheria." 


332  ELECTRO-THERAPEUTICS, 

physical  exertion,  after  hot  baths,  the  injection  of  alcohol,  narcotic  or 
other  medication  ;  chloral,  chloroform,  caffein,  or  kola.  It  has  revealed, 
however,  that  the  outline  of  the  heart  is  smaller  in  the  upright  position 
than  when  the  subject  reclines.  He  believes  that  an  interesting  field 
for  research  is  opened  by  orthodiagraphy  of  the  dilated  heart,  whereby 
we  can  study  the  influence  exerted  upon  it  by  rest  in  bed,  digitalis. 
carbonated  baths,  electric  baths  and  gymnastics,  etc.  H.  Dietlen1 
states  that  he  has  examined  47  out  of  65  patients  suffering  from 
diphtheria  with  the  aid  of  the  Moritz  orthodiagraph,  the  subjects  reclin- 
ing, and  he  found  that  20  of  these  47  presented  evidences  of  myocard it  ic 
phenomena.  In  15  of  this  group  (75  per  cent,  of  the  cases  of  endocar- 
ditis and  32  per  cent,  of  the  total  number),  dilatation  of  the  heart 
was  unmistakably  apparent  when  examined  with  the  orthodiagraph. 
Even  extreme  degrees  of  dilatation  are  liable  to  retrogress,  so  that  the 
prognosis  is  not  necessarily  bad. 

Examination  of  the  Heart. — Kraus2  has  analyzed  the  findings  of  radio- 
scopy of  the  heart  in  health  and  disease.  He  asserts  that  the  shades  of 
difference  between  the  heart  shadows  cast  in  cases  of  various  valvular 
affections  are  of  greater  diagnostic  importance  than  dilatation  of  the 
heart  alone.  These  differences  in  shadows  are  due  to  changes  in  the 
shape  of  the  various  sections  of  the  heart,  the  immediate  consequence  of 
the  valvular  defect.  The  consecutive  hypertrophy  of  the  musculature 
and  passive  dilatation  naturally  reinforce  and  emphasize,  as  it  were,  the 
differences  in  the  outline.  This  is  especially  marked  in  the  left  convex 
protrusion  of  the  so-called  left  middle  arc  in  case  of  mitral  defect,  also  in 
the  varying  behavior  of  the  left  lower  arc  with  mitral  insufficiency  and 
pure  mitral  stenosis,  and,  finally,  in  the  outline  of  the  shadow  as  it 
spreads  to  the  right,  in  case  of  aortic  and  mitral  defects.  Radioscopy 
of  the  heart  after  artificial  distention  of  the  stomach  is  very  instructive. 
The  presystolic  pulsation  of  the  right  auricle  can  be  distinctly  distin- 
guished from  the  contraction  of  the  ventricle.  Two  and  sometimes  three 
contractions  of  the  auricle  to  one  of  the  ventricle  are  sometimes  noted. 
Intermittence  of  the  heart  is  seen  to  be  by  no  means  always  identical 
with  iuterinittence  of  the  pulse.  In  cases  of  tachycardia  and  bradycardia 
radioscopy  throws  light  on  many  hitherto  unexplainable  processes, 
especially  those  of  nervous  origin. 

Pericarditis  (Pericardia!  Effusion}. — If  an  enlarged  shadow  is  cast  by 
the  cardiac  area,  it  indicates  hypertrophy,  or  a  pericarditis  with  effusion. 
If  there  is  presented  a  movement  of  the  left  border  of  the  heart's  shadow, 
it  indicates  enlargement.  In  case  no  such  pulsation  is  demonstra- 
ble, pericarditis  with  an  effusion  should  be  surmised.  The  shadow  of  a 

1  Miinchener  medirinisrh.'  \Vo<-h<.'ns<-hrift,  lii.,  No.  15,  April  11,  1905:  "A<-uU> 
dilatation  of  the  heart  dur  to  diphtheria." 

•  hcutsrhc  incdidnische  Wndu-nM-lirift,  lU-rlin  ami  Ldpsic,  xxxi.,  No.  :i,  .January 
19  ;  Journal  of  the  American  Medical  Association,  June  10,  1905. 


APPLICATION  OF  THE  X-RAYS.  333 

pericardia!  effusion  is  rounded  or  circular,  while  that  of  hypertrophy  is 
more  or  less  pyriform.  lu  most  cases  the  shadow  cast  by  an  effusion  is 
not  so  dense  as  that  produced  by  the  heart  muscle  itself,  so  that  in  view- 
ing the  shadow  field  we  may  find  a  variety  of  shades  ranging  from  a 
slightly  lighter  field  to  one  that  is  dark.  A  change  in  the  upper  level  of 
the  shadow  may  occasionally  be  noticed  by  changing  the  position  of  the 
patient. 

Aortic  Aneurism. — Cases  of  aneurism,  unsuspected  and  unrecognized 
by  the  attending  physicians,  have  been  revealed  by  careful  fluoroscopic 
and  skiagraph ic  examinations.  While  aneurisms  are  sometimes  un- 
detected by  X-ray  examinations,  a  large  number  are  supposedly  diag- 
nosed that  in  reality  do  not  exist ;  an  early  diagnosis,  therefore,  is  most 
important.  The  prognosis  of  aneurism  was  formerly  regarded  as  most 
unfavorable,  but  in  the  light  of  recent  knowledge  the  so-called  "com- 
mencing aneurisms  of  the  aorta"  have  been  shown  to  remain  often 
stationary,  and  that  they  do  not  necessarily  proceed  to  a  fatal  termina- 
tion. They  can  always  be  studied  during  treatment  as  to  their  size, 
position,  pulsation,  etc. 

Fluoroscopic  examinations  are  preferred  by  most  operators  because 
they  are  enabled  to  see  the  tumor  or  pulsating  condition  and  because  the 
condition  can  be  examined  from  different  angles  and,  positions.  Both 
methods  should  be  employed,  although  I  never  use  the  fluoroscope. 

The  skiagraphic  examination  is  identical  with  the  technic  described 
on  diseases  of  the  lungs  and  heart. 

The  shadow  of  the  normal  aorta  (when  viewed  anteriorly  or  posteri- 
orly) is  almost  totally  obscured  by  the  superimposed  shadows  of  the 
sternum  and  the  vertebral  column,  with  the  exception  of  a  small  shadow 
to  the  left,  cast  by  the  left  lateral  a  rtic  bulge. 

Aneurisms  of  the  ascending  portion  of  the  arch  of  the  aorta,  being 
nearer  to  the  anterior  wall  of  the  chest  than  the  posterior  wall,  cast 
shadows  extending  to  the  right  of  the  sternum  and  above  the  heart. 

Aneurisms  of  the  descending  portion  of  the  arch  of  the  aorta 
(Figs.  185  and  186)  usually  cast  shadows  to  the  left  of  the  sternum,  which 
are  nearer  the  posterior  than  the  anterior  wall  of  the  chest.  If  the 
aneurism  is  very  large,  the  shadow  will  extend  to  both  sides  of  the 
sternum. 

Aneurisms  of  the  transverse  portion  of  the  arch  of  the  aorta  will  cast 
shadows  slightly  to  the  left,  and  if  large  the  shadow  observed  will  extend 
up  to  the  neck.  This  detection,  however,  is  very  difficult,  and  requires, 
in  addition  to  anterior  and  posterior  examinations,  left  lateral  and  right 
lateral  oblique  examinations. 

Beginning  or  diffused  aneurisms  are  difficult  of  diagnosis,  especially 
so  in  corpulent  individuals.  Gocht l  declared  that  by  means  of  the 

1  Lehrbuch  der  Rontgenuntersuchung,  Stuttgart,  1898,  p.  199. 


334  ELECTRO-THERAPEUTICS. 

Rontgen  rays  it  was  possible  to  determine  the  presence  of  an  aneurism 
where  doubtful  symptoms  were  manifested. 

Dumstrey  and  Metzner '  urged  considerable  caution  in  reaching  con- 
clusions regarding  the  existence  of  aneurisms  by  means  of  the  Rontgen 
rays,  especially  where  physical  signs  or  symptoms  failed  to  be  elicited  ; 
they  furthermore  believe  that  mediastinal  tumors  may  give  rise  to  the 
same  appearance. 

Drs.  Geo.  Pfahler  and  Jos.  Sailer2  assert  that,  after  a  careful  com- 
parative study  with  X-ray  diagnoses  and  post-mortem  examinations  of 
supposed  aneurisms,  they  found  that  the  tortuosity  of  the  aorta  was 
in  many  instances  confounded  with  the  existence  of  aneurisms. 

Dr.  G.  H.  Orton3  says  that,  "In  some  cases,  even  with  these  four 
examinations,  the  shadows  of  the  aorta  cannot  be  satisfactorily  inspected, 
owing  to  complications  which  may  mask  it." 

Of  late,  I  am  making  stereo-skiagrams  of  the  chest,  and  find  them 
valuable  in  differential  studies  involving  the  aorta,  heart,  and  lungs  in 
their  respective  relations  to  each  other  and  to  the  bony  thorax. 

In  many  cases  of  small  aneurism,  the  oblique  method  of  examination 
should  be  employed.  This  has  been  well  described  by  Holzknecht 
andBeclere:4  "It  consists  in  rotating  the  patient  so  that  the  rays 
penetrate  the  chest  obliquely.  If  the  screen  is  placed  on  the  left  of  the 
patient  and  the  tube  on  the  right  side,  the  pericardial  shadow  is  bounded 
by  two  clear  spaces ;  the  retrosternal  in  front,  and  the  retrocardiac 
behind.  In  this  position  the  inferior  parts  of  the  ascending  and  descend- 
ing aorta  can  be  seen,  but  the  arch  is  hidden  by  the  shadows  of  the 
shoulder  muscles  and  vertebral  column. 

"Now  if  the  patient  is  rotated  so  that  the  rays  penetrate  the  chest 
at  an  angle  of  45°  forward  and  from  left  to  right,  the  best  position 
is  obtained.  In  this  position  the  cardiac  shadow  is  angular,  the  lusc 
continuous  with  the  diaphragm,  the  superior  angle  prolonged  into  a 
vertical  offshoot,  caused  by  the  superimposed  shadows  of  the  ascend- 
ing and  descending  parts  of  the  arch.  In  this  position  many  cases 
of  supposed  aneurism  which  show  the  marked  aortic  bulge  in  the 
antero-posterior  examination  are  shown  not  to  be  true  aneurisms.  In 
suspected  cases  the  examination  is  not  complete  until  this  method  has 
been  employed." 

Another  important  sign  in  the  diagnosis  of  aneurism,  first  pointed 
out  by  Walsham,  consists  in  a  change  in  the  position  of  the  heart,  which 
comes  to  lie  more  transversely,  the  right  side  being  apparently  pushed 
down  by  the  aneurism,  with  a  tilting  upward  of  the  apex.  Orton,  like- 
wise, regards  the  position  of  the  heart  as  a  very  valuable  and  constant 

1  Fortschritte  auf  dem  Gebiete  der  Rontgenstrahlen,  vol.  i. 

2  The  American  Journal  of  the  Medical  Sciences,  October  1,  1903. 
'Archives  of  the  Kontgen  Kay,  August,  1905. 

*  Archives  of  Physiological  Therapy,  October,  1905. 


FIG.  185. — Aneurism  of  the  descending  aorta  (posterior  view).    Plate  applied  against  the  back 

of  the  chest. 


FIG.  186.— Photographic  tracing  of  the  same.    Heavy  lines,  outlines  of  normal  heart ;  dotted  lines, 

dilatation  of  the  descending  (D-< )  aorta.    Observe  the  horizontal  position  of  the  heart,  due  to 

aneurismal  pressure.    A >• ,  ascending  aorta  ;  T  •< ,  transverse  aorta. 


APPLICATION  OF  THE  X-RAYS. 

sign.     There  are  shadows  that  may  exist  either  to  the  right  or  left  of  the 
sternum  which  may  be  confounded  with  the  diagnosis  of  aneurism. 

1.  Dilatation  of  the  aorta  (not  aneurismal). 

2.  Displaced  aorta  ( dislocated). 

3.  Enlarged  glands. 

4.  Neoplasms. 

5.  Pulsating  empyema. 

1.  Dilatation  of  the  Aorta  (Fig.  187). — This  condition  is  often  con- 
founded with  aneurism  ;  the  shadow  cast  will  be  on  either  side  of  the 
sternum,  the  diagnostic  point  being  that  this  pulsating  shadow  will  dis- 
appear between  the  pulsations  (the  diastole);  because  with  the  contrac- 
tion of  the  aorta  the  shadow  thrown  will  be  smaller,  or  it  will  be  com- 
pletely hidden  by  the  shadows  cast  by  the  sternum  and  vertebral  column. 
In   this  differentiation  the  fluoroscopic  examination  will   prove   more 
useful  than  will  the  skiagraph. 

2.  Displaced  Aorta. — This  condition  usually  appears  to  the  left  of 
the  spinal  column,  a  pulsating  shadow  being  evidenced  as  far  as  five  or 
six  inches  to  the  left  of  the  border  of  the  sternum.     This  is  a  much 
greater  area  than  will  be  projected  by  the  aneurism  of  the  arch. 

Abnormalities  of  the  thorax  and  spine  should  be  excluded. 

3.  Enlarged    Glands. — Enlarged    lymphatic    and    bronchial    glands 
cast    scattered  shadows,   with   absence  of  the  characteristic  expansile 
pulsations. 

4.  Neoplasms. — Mediastinal  growths,  i.  e.,  carcinoma  and  sarcoma, 
can  be  differentiated,  in  that  the  latter  cast  darker  or  denser  shadows, 
the  edges  are  hazy,  indistinct,  and  uniform,  and  by  the  absence  of  ex- 
pansile pulsations.    Care  should  be  exercised  not  to  overlook  transmitted 
pulsations. 

.">.  rnlxatiii(i  Empyema. — Pulsating  empyema  and  other  intra-thoracic 
abscesses  will  be  differentiated  by  the  history,  their  location,  and  form. 

Aneurisms  of  the  abdominal  aorta  cannot  be  well  demonstrated  in 
corpulent  persons,  owing  to  lack  of  contrast  with  the  surrounding  tissues, 
as  the  shadows  of  the  aorta  and  vertebrae  superimpose,  when  skiagraphed 
in  either  the  ventral  or  dorsal  positions.  Lateral  and  oblique  positions 
are  always  advisable  in  skiagraphing  this  condition. 

Aihcroma. — Atheroma  and  calcification  of  the  blood-vessels  can  be 
well  demonstrated.  (Fig.  188.) 


CHAPTER  V 

APPLICATION  OF  THE  X-KAYS  IX  DISEASES  OF  THE 
ABDOMINAL  OEGANS. 

I.  Alimentary  System. 

THE  employment  of  the  X-rays  in  the  diagnosis  of  diseases  of  the 
alimentary  system  has  not  as  yet  yielded  the  same  results  or  been  as 
easy  of  application  as  is  evidenced  in  diseases  of  the  thoracic  organs, 
for  the  obvious  reason  that  there  exist  no  tissue  differences. 

There  are  various  means  of  producing  the  necessary  contrast  or 
difference  between  these  soft  tissues  :  (1)  by  gaseous  distention,  which 
renders  the  stomach  more  translucent ;  (2)  by  the  introduction  of 
opaque  instruments  or  mechanical  methods ;  (3)  the  bismuth  subnitrate 
method,  by  which  the  organs  become  more  opaque  ;  (4)  the  transilluini- 
nation  method,  which  consists  in  illuminating  the  stomach  by  the  intro- 
duction of  fluorescent  materials,  radium,  etc. 

A.    CESOPHAGUS. 

In  order  to  examine  this  tubular  muscular  organ,  for  its  position, 
direction,  etc.,  we  may  introduce  a  rubber  sound  with  a  metal  point,  or  a 
rubber  tube  filled  with  mercury  or  fine  shot. 

The  fluoroscopic  examination  should  be  made  with  the  patient  in  the 
semi-recumbent  or  standing  position,  so  as  to  prevent  the  superimposition 
of  the  shadows  cast  by  the  vertebrae,  heart,  aorta,  etc.  Allow  the  shadow 
to  fall  on  a  clear  area  and  apply  the  fluoroscope  obliquely  over  the  right 
and  left  sides,  and  also  in  the  right  and  left  antero-lateral  positions. 

Skiagraphic  examinations  should  be  made  in  the  same  positions 
as  in  the  fluoroscopic  method,  but  the  posterior  position  is  more  com- 
fortable for  the  patient. 

Stricture  of  the  (Esophagus. — Constrictions  of  the  oesophagus  can  be 
best  ascertained  by  the  introduction  of  a  bougie  with  metallic  ends,  or 
by  the  use  of  a  metallic  sound,  and  viewing  its  passage  in  the  above 
manner. 

Stenoses  of  the  (Esophagus. — Barba1  reports  two  cases  of  oesophageal 
stenoses,  in  which  he  made  radioscopic  observations.  The  chief  point 
brought  out  in  his  study  is,  that  the  ordinary  methods  of  examination  for 
stenosis  of  the  oesophagus  (the  most  important  of  which  is  the  use  of 
sounds)  do  not  enable  us  to  differentiate  an  organic  stenosis  of  the  canal 
from  a  narrowing  occasioned  by  the  pressure  of  tumors  in  the  mediasti- 
num or  by  other  causes  of  compression.  The  presence  of  these  causes  of 

1  Riforma  Medica,  December  23,  1905. 
336 


DISEASES  OF  THE  ABDOMINAL  ORGANS.  337 

compression  in  the  mediastinum  is  very  difficult  to  determine  by  physical 
examination,  and  only  the  Rontgen  rays  enable  us  to  make  an  accurate 
diagnosis.  In  the  two  cases  reported,  radioscopy  showed  that  the  ste- 
nosis, in  each,  was  caused  by  the  compression  of  tumors  in  the  posterior 
mediastinum.  In  both  cases,  the  radioscopic  examination  was  aided  by 
the  passage  of  a  sound  filled  with  a  concentrated  solution  of  bismuth 
subnitrate,  or  else  provided  with  a  metallic  stylet. 

Divert  ieul  urn. — A  diverticulum  may  often  be  diagnosed  by  the  above 
method.  The  bougie  or  sound  may  not  enter  into  the  pouch,  however, 
when  it  becomes  necessary  for  the  patient  to  drink  bismuth  suspended  in 
water  ;  one  to  two  parts  to  100  parts  of  water.  When  possible,  skiagraphs 
should  be  taken,  as  it  requires  but  a  few  minutes  and  the  operator  does 
not  endanger  his  hands. 

Tumors. — Dr.  Hugh  Walsham l  reports  two  cases  of  carcinoma  of  the 
oesophagus.  He  says  that,  "  we  must  not  expect  so  definite  a  shadow 
as  seen  in  cases  of  aortic  aneurism."  The  diagnosis  of  an  oesophageal 
growth  is  more  difficult  than  that  of  aneurism. 

Before  the  screen  examination  he  gives  the  patient  two  drams  of 
carbonate  of  bismuth,  suspended  in  a  little  milk  or  mucilage.  This 
will  map  out  the  seat  of  the  obstruction,  whilst  the  topography  of  the 
cesophagus  can  be  traced  by  a  metallic  bougie. 

B.  STOMACH  :    SIZE.  SHAPE,  AND  POSITION. 

Examination  by  Aid  of  Gaseous  Distent  ion. — This  method  consists  in 
distending  the  stomach  by  the  ingestion  of  certain  chemical  agents 
which  upon  reaction  result  in  the  evolution  of  gases.  The  chemical 
most  frequently  employed  is  Seidlitz  powder.  Upon  the  fluoroscope  the 
stomach  appears  as  a  dark  area,  upon  the  negative  as  a  light  area.  This 
method  causes  the  distention  of  the  stomach  walls  and  the  displacement 
of  the  surrounding  organs,  so  that  little  information  can  be  gained  by 
this  procedure. 

Mfflmnirtil  Method. — In  this  method,  a  rubber  tube  containing  a 
spirally  coiled  wire  is  introduced  through  the  mouth  into  the  stomach. 
Turck's  gyromele  is  a  device  employed  to  determine  the  outline  of  the 
stomach  by  iluoroscopic  means. 

Neumann 2  uses  a  Politzer  rubber  bulb  with  a  soft  stomach  tube  for 
aspiration  of  the  stomach  contents.  After  the  stomach  has  been  emptied 
and  a  clean  bulb  attached  to  the  tube,  it  is  possible  to  determine  the  out- 
line of  the  stomach  with  great  precision,  by  listening  to  the  sound  when 
air  is  forced  from  the  rubber  bulb  into  the  stomach.  A  small  amount  of 
air  is  sufficient  for  the  test,  thus  avoiding  distention  of  the  organ. 
In  every  instance  radioscopy  confirms  the  findings  of  auscultation  as 

1  Archives  of  the  Rontgen  Ray,  April,  1903,  p.  114. 

1  Journal  of  the  American  Medical  Association,  July  23,  1904. 


;;;;s  ELECTRO-THERAPEUTICS. 

the  bulb  is  compressed  and  the  air  forced  into  the  stomach.  This  test 
is  useful  in  dubious  cases  in  the  differentiation  of  gastric  from  intestinal 
stenosis. 

The  Hisiniith  Xnl>  nit  rate  Method. — This  method  consists  of  the  inges- 
tion  of  subnitrate  of  bismuth,  either  mixed  with  food  suspended  in  water, 
or  administered  in  capsule  form.  This  method  was  introduced  and  first 
employed  by  MM.  J.  Ch.  Roux  and  Balthazard.1  In  1897,  F.  Williams, 
of  Boston,  applied  this  method  most  extensively.  The  employment  of 
the  bismuth  test,  at  the  present  time,  is  universal. 

Technic  of  the  Bismuth  Method. — Chemically  pure  bismuth  subnitrate 
should  always  be  employed.  Cases  of  poisoning,  though  not  fatal,  have 
been  reported  where  the  impure  salt  was  taken.  The  stomach  should  be 
empty,  no  water  should  be  partaken  of,  and  the  bowels  should  be 
thoroughly  purged  twenty-four  hours  prior  to  the  examination.  Roux 
and  Balthazard  use  bismuth  subnitrate  in  the  proportion  of  0.20  per  cubic 
centimetre.  Williams  has  administered  as  much  as  one  ounce  of  bismuth 
emulsion.  Hultz  gives  the  patient  the  bismuth  in  a  pint  or  more  of 
milk.  Boas  advises  the  partaking  of  bread  and  milk  or  of  potato  soup, 
into  which  has  been  stirred  one  ounce,  or  more,  of  the  bismuth  salt. 

Fluoroscopic  Examination. — Williams  recommends  examination  of  the 
patient  with  the  fluoroscope,  as  "  the  stomach  moves  during  respiration, 
and  therefore  its  outlines  are  blurred  on  the  radiograph."  2 

Holzkuecht  and  Brauner 3  assert  that  the  passage  of  a  bismuth  tablet 
into  the  stomach  can  be  traced  and  its  expulsion  watched,  and  that  "the 
action  of  massage  on  the  stomach,  displacement  of  the  organ  during 
respiration,  etc.,  can  be  better  studied  by  a  fluoroscopic  examination." 

1  do  not  employ  the  fluoroscope,  as  it  is  dangerous  alike  for  the 
operator  and  patient,  and  because  the  taking  of  a  skiagraph  is  only  a 
question  of  seconds.     A  severe  X-ray  dermatitis  occurred  in  the  hospital 
while  the  attending  physician  and  my  assistant  were  examining  such  a 
case  with  the  fluoroscope. 

Skiagmphic  Examination. — The  patient  lies  over  a  14  x  17  inches 
(35  x  43  cm.)  plate,  a  penny  being  placed  over  the  umbilicus  and  then 
secured  by  adhesive  plaster.  The  patient  must  remove  his  clothing. 
The  ventral  or  dorsal  decubitus,  sitting,  standing,  or  semi -recumbent 
position  may  be  employed. 

In  the  ventral  position,  the  anterior  wall  of  the  stomach  comes  in 
contact  with  the  plate.  In  the  dorsal  position,  the  posterior  wall  will  be 
nearer  to  the  plate.  In  the  sitting  or  standing  position,  the  weight  of 
the  bismuth  will  depress  the  lower  border  of  the  stomach,  so  very  impor- 
tant in  the  study  of  cases  of  gastroptosis.  The  ventral  position  is  to  be 

'C.  R.  tie  1'Academie  des  Sciences,  1896.  Bouchard,  Trait*-  de  Radiologie  Mt'di- 
cale,  p.  995. 

2  William*,  The  Rontgen  Rays  in  Medicine  and  Surgery,  p.  367. 
•Wiener  klin.  Rundschau,  1905,  vol.  xliv.  p.  1971. 


DISEASES  OF  THE  .ABDOMINAL  OIHJAXS.  339 

preferred,  because  the  bismuth  adheres  upon  the  anterior  gastric  wall. 
presenting  clearly  the  fundus,  the  cardiac  end,  and  the  general  contour 
of  the  organ. 

The  Crookes  tube  should  have  a  high  vacuum.  The  anode  is  placed 
perpendicularly  over  the  third  and  fourth  lumbar  vertebrae,  at  a  distance 
of  20-25  inches  (50-63  cm.)  from  the  plate. 

Time  of  Exposure.  —  The  time  of  exposure  should  be  as  short  as 
possible,  because  of  the  danger  of  blurring,  occasioned  by  peristalsis  and 
from  the  diaphragmatic  movements.  The  exposure  can  be  made  suffi- 
ciently short  either  after  a  full  inspiration  or  after  a  forced  expiration. 
Narcotics  to  lessen  peristalsis  are  seldom  necessary.  In  corpulent 
subjects,  especially  when  the  apparatus  is  inadequate,  the  intensifying 
screen  can  be  used  ;  but  when  a  fine  negative,  full  of  detail,  is  to  be 
brought  out,  the  granularity  produced  by  the  screen  is  a  serious  disad- 
vantage. I  employ  a  high-vacuum  tube,  with  an  electrolytic  interrupter, 
duration  3  to  15  seconds,  thus  allowing  the  patient  to  hold  his  breath 
after  a  full  inspiration. 

Dr.  Henry  K.  Pancoast 1  reported  the  cases  of  40  patients,  suffering 
with  gastric  or  gastro-intestinal  symptoms.  The  technic  he  employs  is  as 
follows:  " Bismuth  subnitrate  held  in  suspension  in  mucilage  of  acacia 
(proportion  of  two  ounces  of  the  powder  to  the  pint)  (or  64  grams  to 
one-half  litre)  was  either  poured  into  the  stomach  through  the  stomach 
tube  or  was  swallowed  by  the  patient ;  the  latter  method  was  principally 
used.  The  bulk  of  the  bismuth-acacia  mixture  varied  from  six  to 
thirty-two  ounces  (190  to  700  grams).  Immediately  after  the  bis- 
muth had  reached  the  stomach  the  pictures  were  taken,  the  patient 
being  in  the  standing  position,  and  the  plate  in  contact  with  the  anterior 
abdominal  wall. 

uThe  rays  were  thrown  posteriorly,  the  patient  holding  the  breath 
during  full  inspiration  for  an  exposure  of  eight  to  fifteen  seconds  ;  thus 
eliminating  blurring  by  respiratory  and  peristaltic  movements.  After 
the  picture  has  been  taken,  it  is  advisable  to  siphon  the  bismuth  mixture 
out  of  the  stomach. 

"In  several  cases  as  much  as  four  ounces  of  bismuth  was  left  in  the 
stomach  with  no  unpleasant  symptoms  ;  but  on  the  other  hand,  six  cases 
showed  toxic  symptoms  after  this  amount  had  not  been  removed.  For 
the  purpose  of  obtaining  the  lower  border  and  segment  of  the  stom- 
ach, six  ounces  of  the  emulsion  containing  one  ounce  (32  grams)  of 
bismuth  is  sufficient.  This  amount  has  been  left  in  the  stomach  with 
no  bad  effects." 

Dr.  Joseph  Sailer,  of  Philadelphia,  has  reported  untoward  symp- 
toms following  the  administration  of  bismuth.  The  symptoms  varied, 
but  cyanosis,  dyspnrea,  nausea,  etc.,  were  noted  in  several  patients.  The 

1  University  of  Pennsylvania  Medical  Bulletin,  August,  1906. 


340  E LK(  T K(  )-T  II I •  I!  A  1 >  K I ' T I ( 'S. 

presence  of  antimony  and  arsenic  was  excluded,  and  it  was  thought  that 
the  rays  had  a  peculiar  action  on  the  trypsin,  with  disintegration  of  the 
subuitrate.  Undoubtedly  the  action  only  started  after  the  bismuth  had 
been  for  some  period  in  the  intestine,  and  had  been  acted  upon  by  the 
ferments  present.1 

Dr.  Henry  Hultz2  asserts  that:  ;' Immediately  after  the  bismuth 
nieal  two  dorso-ventral  exposures  are  to  be  made,  one  in  the  standing  or 
sitting  position,  and  one  in  the  recumbent  position.  Assuming  that  the 
first  Eontgenographs  were  taken  at  noon,  the  next  one  should  be  mad*- 
about  six  hours  later,  the  patient  having  partaken  of  neither  fluids  nor 
solids  since  the  noon  hour." 

He  employs  the  following  technic  :  A  16-inch  coil,  Wehnelt  inter- 
rupter, but  one  intensifying  screen,  a  strong  tube  yielding  Walter  six 
rays,  placed  20  inches  (50  cm.)  from  the  plate.  He  succeeded  easily 
in  skiagraphing  the  stomach  of  a  medium-sized  subject  in  one  second, 
and  obtained  a  very  good  plate  taken  under  the  same  conditions  but 
without  the  use  of  intensifying  screens  in  three  seconds.  He  prefers  an 
exposure  of  ten  seconds  without  the  screen. 

Holzknecht  and  Brauner 3  recommend  the  following  technic  :  The 
views  are  taken  standing  and  reclining  and  during  inspiration  and  expi- 
ration ;  the  most  important  information  generally  being  obtained  by  radi- 
oscopy. To  examine  the  standing  patient,  the  Eontgen  tube  and  the  fluo- 
rescent screen  are  suspended  by  weights  from  a  wooden  standard,  parallel 
to  each  other.  The  patient  swallows  a  tablet  of  bismuth  and,  after  its 
course  has  been  traced,  he  drinks  50  grammes  of  water  into  which  10 
grammes  of  bismuth  have  been  stirred.  After  the  findings  of  this  test 
ha\  i'  been  noted,  the  patient  is  directed  to  drink  a  mixture  of  4  grammes 
of  tartaricacid  and  5  grammes  of  sodium  bicarbonate.  On  the  following 
day,  the  patient  is  given  400  grammes  of  milk  gruel  containing  35  grain  nu-s 
of  bismuth  while  he  reclines  on  the  left  side,  with  the  Eontgen  tube  applied 
to  the  dorsal  aspect  of  the  body  ;  subsequently  he  is  examined  when 
lying  on  the  right  side  and  again  when  in  the  dorsal  posture. 

Heinmeter  of  Baltimore4  has  recently  used  the  following  method  : 
"The  dilated  stomach  is  coated  internally  with  bismuth  subnitrate  by 
means  of  a  powder  blower,  after  which  its  outline  can  be  distinctly 
recognized  through  the  fluoroscope." 

Eieder5  says:  "Let  the  patient  swallow  a  mixture  of  10  or  15  grammes 
of  bismuth  subnitrate  suspended  in  50  c.c.  of  water,  and  observe  deglu- 
tition by  the  fluoroscope.  The  act  of  swallowing  may  be  studied  more 
leisurely  if  a  small  quantity  of  the  bismuth  salt  be  given  in  a  pill.  For 

'University  of  Pennsylvania  Medical  Bulletin,  August,  1906. 
1  Transactions  of  the  American  Rontgen  Ray  Society,  1906,  p.  45. 

Wiener  klin.  Rundschau,  vol.  xliv.  p.  1971. 
4  Diseases  of  the  Stomach,  p.  640. 
•  Miinchener  merl.  Woch.,  epitome  in  Medical  Record,  Feb.  10,  1906. 


DISEASES  OF  THE  ABDOMINAL  ORGANS.  341 

more  exact  observation,  a  bismuth  meal  is  employed.  Thirty  grammes 
of  bismuth  subnitrate  are  mixed  with  a  little  milk  and  this  is  then  added 
to  300  or  400  grammes  of  flour  gruel,  sweetened  with  milk-sugar  to 
obviate  constipation." 

Dalton  and  Reid '  obtain  the  position  of  the  stomach  by  the  employ- 
ment of  an  O2sophageal  tube  containing  bismuth. 

The  TransiUumination  Method. — This  method  consists  iu  introducing 
some  radio-active  substances,  or  an  electric  light  or  air  into  the  stom- 
ach, and  then  viewing  the  viscus  with  the  fluoroscope  or  by  taking  a 
skiagraph. 

Max  Einhorn 2  remarks  that :  "  TransiUumination  into  the  stomach 
can  be  demonstrated  with  Kahlbaum's  barium  platino-cyanide,  or  by 
means  of  a  photographic  plate.  The  latter  method  has  the  advantage 
that  no  dark  room  is  required  and  that  the  result  obtained  is  visible  to 
every  one,  leaving  nothing  for  imagination  or  speculation. 

"In  order  to  procure  a  radium  photograph  of  the  stomach  I  pro- 
ceed as  follows  :  The  patient  should  be  in  the  fasting  condition  (empty 
stomach).  The  radio-diaphaue,  containing  0.05  gm.  (or  more)  of  pure 
radium  bromide,  is  introduced  into  the  stomach.  The  patient  occupies 
a  recumbent  position,  and  a  photographic  plate  is  put  directly  over  the 
gastric  region  and  allowed  to  remain  there  for  one  or  two  hours,  accord- 
ing to  the  requirement  of  the  case.  The  plate  is  then  removed  and  the 
radio-diaphaue  withdrawn.  The  plate  is  then  developed. 

''Contrary  to  my  expectations,  radium  enclosed  in  a  quartz  flask 
failed  utterly  to  transmit  the  photographic  rays,  while  thin  ordinary 
glass  answered  the  purpose  very  well. 

"The  shortest  time  for  obtaining  a  photographic  outline  of  the 
stomach  is  one  hour  ;  in  less  than  an  hour  hardly  anything  is  visible  ;  one 
and  a  half  to  two  hours  bring  out  the  outlines  more  distinctly.  Insuffla- 
tion of  air  into  the  stomach  occasionally  aids  in  obtaining  a  good  picture. 

u  A  few  of  the  better  radium  photographs  in  my  possession  are 
reproduced  herewith  and  show  that  transillumiuation  of  the  stomach  by 
means  of  radium  is  feasible.  It  is  even  possible  to  recognize  an  area  of 
light  which  had  to  pass  through  the  posterior  wall  of  the  stomach  and 
the  back  of  the  thorax.  One  of  my  negatives  shows  a  key  which  was 
hanging  below  the  left  scapula  and  was  thus  photographed  by  the  trans- 
mitted light  troui  the  stomach. 

"Considerable  sized  tumors  of  the  stomach  or  liver  can,  sometimes,  be 
recognized  on  the  picture  by  the  diminished  trauslucencj'.  Thus  far,  how- 
ever, I  have  not  succeeded  in  obtaining  definite  outlines  of  the  growth." 

Sinclair  Tousey s  finds  the  radio-active  and  fluorescent  solutions,  as 

1  Lancet,  April  1,  1905. 

*  Archives  of  Physiological  Therapy,  Sept.  1905,  p.  115. 

3  New  York  Medical  Journal,  May  21,  1904. 


;>t_'  ELECTRO-THERAPEUTICS. 

prepared  by  him  with  quinine  bisulphate  and  fluoresciu.  are  innocuous 
when  given  by  the  mouth  or  subcutaneously,  but  do  not  produce  singly, 
or  in  combination,  sufficient  fluorescence  to  be  of  value  in  the  examina- 
tion of  the  stomach  without  the  use  of  some  additional  light  to  excite 
their  fluorescence.  In  some  cases,  however,  they  will  be  of  the  greatest 
assistance  in  the  diagnosis  of  stomach  lesions,  and  at  times  of  advantage 
in  X-ray  treatment. 

In  cases  of  gastroptosis,  I  have  had  experience  with  this  method  at 
the  Philadelphia  Hospital,  where  it  has  not  afforded  me  any  satisfaction. 

C.  THE  CLINICAL  APPLICATION  OF  THE  BAYS. 

Stomach. — The  behavior  of  the  stomach  during  digestion  has  been 
studied  with  the  X-rays  on  cats  and  dogs  by  W.  B.  Cannon.1  The  out- 
line of  the  stomach  was  reproduced  on  the  screen  by  giving  the  animal 
small,  but  frequently  repeated  doses  of  bismuth  subuitrate.  After  a 
plentiful  feeding  the  viscus  was  observed  to  be  considerably  larger, 
gradually  diminishing  in  size  as  the  process  of  digestion  proceeded  ;  at 
the  same  time,  the  cardiac  end  acted  as  a  reservoir  for  the  ingested  food 
while  the  pyloric  region  presented  marked  peristaltic  movements.  It  was 
further  noted  that  liquids  soon  pass  from  the  stomach,  while  solids  remain 
there  for  an  indefinitely  longer  period. 

The  activity  of  the  digestive  juices  can  be  determined  by  giving  the 
patient  a  small  quantity  of  bismuth  iu  a  small  capsule  of  gold-beater's 
skin  or  gelatine.  As  the  patient  swallows,  the  shadow  of  the  opaque 
spot  is  demonstrable  on  the  fluorescent  screen  so  long  as  the  capsule  is 
intact.  When  the  gold-beater's  skin  has  been  disintegrated  by  the  action 
of  the  digestive  juices,  the  particles  of  bismuth  become  diffused  and 
the  black  spot  is  no  longer  seen  on  the  photographic  plate  or  screen. 
The  time  occupied  by  the  digestion  of  the  capsule  is  a  measure  of  the 
activity  of  the  stomach  and  the  quality  of  the  peptic  juices. 

Repeated  examinations  will  reveal  the  time  that  is  required  to  empty 
the  contents  of  the  stomach.  The  bismuth  accumulates  near  the  py- 
loric end  aud  passes  to  the  intestines.  This  consumes  a  period  of  about 
6  or  7  hours. 

Position  of  tfie  Stomach. — Butler 2  asserts  that :  "  The  lower  border  of 
a  normal  but  much  distended  stomach  may  be  found  at  the  level  of  the 
navel.  If  below  the  umbilicus  the  condition  is  abnormal."  Quain  believes 
that :  "  It  is  generally  a  little  (half  an  inch  to  an  inch)  above  the  highest 
point  of  the  iliac  crest,  and  about  opposite  the  disk  between  the  third 
and  fourth  lumbar  vertebra."8  The  shadows  of  the  normal  stomach 
being  approximately  known,  any  increase  or  decrease  in  the  interval  from 

1  American  Journal  of  Physiology,  vol.  i.,  May  1,  1898. 

"  I  >iagnostic8  of  Internal  Medicine,"  p.  543. 
1  Quain's  Anatomy,  vol.  i.,  p.  679. 


DISEASES  OF  THE  ABDOMIXAL  ORGANS.  343 

the  umbilicus  will  inform  the  skiagraplier  of  any  abnormal  gastric  posi- 
tion. When  the  tube  is  at  a  distance  of  20  inches  (50  cm.)  the  distortion 
will  be  very  small. 

Holzknecht,1  however,  believes  that:  <;A  stomach  which  is  of  nor- 
mal size  and  situated  in  the  normal  position  is  rarely  visible  ;  but  when 
gastroptosis  occurs  the  stomach  becomes  visible.  When  the  walls  of  the 
stomach  are  infiltrated  with  carcinomatous  deposits,  abnormalities  in  the 
contractions  of  the  organ  are  readily  observed,  when  food  mixed  with 
bismuth  is  given  to  the  patient." 

Rieder  had  large  quantities  of  bismuth  mixed  with  the  food  and 
given  in  eneinata.  and  then  examined  the  patients  with  the  screen.  His 
deductions  are  contrary  to  the  teachings  of  text-books.  When  the  stom- 
ach is  full,  the  pylorus,  for  instance,  may  be  found  to  the  left  of  the 
median  line.  The  full  stomach  lies  vertical  or  diagonal,  never  horizontal. 
There  is  always  an  accumulation  of  gas  to  be  noted  in  the  upper  part  of 
the  fuudus  during  stomachic  digestion.  He  also  observed  interesting 
facts  concerning  the  motor  functions  of  the  stomach  and  of  the  various 
parts  of  the  intestines. 

Gastroptosis.  — This  condition  is  best  shown  skiagraphically  (Fig.  189) 
while  the  patient  is  sitting  or  standing,  or  in  both  dorsal  and  ventral 
positions ;  otherwise  the  condition  may  not  be  detected.  Often  there 
will  be  a  difference  in  the  position  of  the  stomach  depending  upon 
whether  the  skiagraph  is  made  after  full  inspiration  or  after  full 
expiration. 

The  form,  size,  and  shape  of  the  stomach  can  be  ascertained  by  a 
careful  study  of  the  normal  stomach  and  then  by  comparing  it  with 
any  supposed  abnormality,  being  careful  that  the  technic  is  identical  in 
each  case. 

G.  Leven  and  G.  Barret2  studied  the  outlines  of  the  stomach  by 
following  the  path  of  a  bismuth  pill,  and  came  to  the  conclusion  that : 
'•  Our  ideas  of  the  shape  of  the  stomach  in  life  demand  revision,  also  that 
the  lower  curve  of  the  organ  does  not  sweep  across  the  abdomen,  but  that 
the  cardiac  end  has  a  small  amplitude  from  which  the  line  runs  inward, 
then  sharply  down  to,  or  below  the  umbilicus,  and  as  sharply  up  again 
towards  the  pylorus. 

1  i  The  form  of  the  stomach  has  therefore  not  the  regular  lines  hitherto 
drawn,  and  such  as  we  see  after  death  ;  but  the  superior  part  is  dimin- 
ished in  size  by  the  dilatation  of  a  tube-like  process  going  downward 
from  the  lower  border  towards  the  navel." 

The  authors  aver  that  in  the  normal  stomach  this  tubular  part  re- 
ceives fluids  till  it  is  full.  When  more  liquid  is  added,  the  tube  begins 
to  expand,  so  that  the  level  of  the  liquid  remains  constant  for  a  time. 
when  the  latter  finally  invades  the  rest  of  the  cavity  of  the  stomach.  On 

1  Berliner  klin.  Wochen.,  February  28,  1906. 
2Presse  Medicale,  Paris,  January  31,  1906. 


344  ELECTRO-THEKAPEUTICS. 

the  other  hand,  in  a  dilated  stomach  the  authors'  characteristic  method 
of  filling  is  not  evident ;  the  fluid  collects  in  the  lower  curve  of  the 
viscus,  and  the  level  rises  slowly  and  regularly. 

Stenosis  of  thePyloric  End. — \Vhen  the  average  time  which  is  neces- 
sary for  the  passage  of  the  food  (bismuth)  for  a  normal  stomach  is  pro- 
longed (over  0  hours),  it  is  indicative  of  stenosis  of  the  pyloric  end,  or 
of  gastric  insufficiency,  either  caused  by  dilatation  or  atony.  The  ski- 
agrapher  should  make  several  exposures  to  determine  the  time  required 
to  empty  the  stomach. 

D.  INTESTINES. 

If  only  the  stomach  is  to  be  examined,  the  bismuth  can  be  pumped 
from  the  stomach  after  the  skiagraphs  are  made ;  if  allowed  to  remain 
for  three,  six,  or  eight  hours,  the  bismuth  passes  into  the  intestinal  canal 
in  15  or  20  hours.  It  is  possible  to  obtain  skiagrams  of  the  colon  and 
other  portions  of  the  intestinal  tract. 

Eieder '  declares  that:  "For  the  large  intestines,  rectal  injections 
may  be  used  ;  and  that  by  the  use  of  one  litre  of  fluid  containing  bismuth 
it  is  possible  to  insure  penetration  as  far  as  the  ileo-csecal  valve." 

Sounding  ami  Radiography  of  the  Large  Intestine. — Schiile2  has  been 
testing  various  sounds,  including  Kuhn's  flexible  spiral  sounds  and  also 
the  Kassel  soft  tubes  with  flexible  metal  guide,  terminating  in  a  button 
2Ho  3*  inches  (5.5  to  8  cm.)  in  circumference,  thus  obviating  all  danger 
of  perforating  the  intestinal  wall.  His  conclusion  is,  that  no  convincing 
proof  has  been  obtained,  to  date,  that  a  sound  has  been  successfully 
passed  into  the  descending  colon,  to  say  nothing  of  the  transverse  portion. 
The  innumerable  folds,  windings,  and  swellings  of  the  intestine  render 
it  impossible  to  determine  whether  an  obstacle  to  the  progress  of  the 
sound  is  of  a  natural  or  a  pathological  nature.  On  the  other  hand,  the 
direct  visual  inspection  of  the  rectum  and  the  sigmoid  flexure  by  the 
J.  Schreiber  and  H.  Strauss  technic  is  perfectly  reliable.  Schiile  found 
that  "high  injections"  were  practicable,  the  best  vehicle  being  oil.  An 
injection  in  the  knee-elbow  position  of  300  to  400  c.  c.  of  oil  with  125 
gm.  of  bismuth  subnitrate,  followed  by  radiography,  showed  that  the  oil 
had  penetrated  to  the  ileo-caecal  valve.  In  two  of  the  patients  there  was 
pronounced  enteroptosis,  the  transverse  colon  in  one  hanging  suspended 
like  a  garland  from  the  two  points  of  attachment  at  each  end,  the  centre 
reaching  far  below  the  upper  plane  of  the  pelvis.  On  account  of  the 
small  amount  of  the  oil  injected,  and  the  fact  that  the  subject  was  in  the 
knee-elbow  position  at  the  time,  the  injection  could  not  have  been 
responsible  for  the  sinking  of  the  intestine.  The  radiograms  show  per- 
fectly the  topography  of  the  colon  for  its  entire  extent.  They  also  prove 

'Munch,  med.  Woch..  epitome  in  Medical  Record,  February  10,  1906. 
'Archiv  f.  Verdauungs-Krankheiten,  Berlin,  last  indexed  page  863. 


DISEASES  OF  THE  ABDOMINAL  ORGANS.  345 

that  the  ileo-ca?cal  valve  is  always  continent.  Tests  on  the  cadaver 
showed  that  extreme  pressure,  beyond  what  would  be  possible  in  the  liv- 
ing subject,  is  necessary  to  force  it  open. 

Intestinal  Obstruction. — Rudis-Jicinsky  *  reports  two  such  cases  :  one, 
a  boy  of  10,  swallowed  a  tin  whistle,  and  the  usual  symptoms  of  intestinal 
obstruction  followed.  The  site  of  the  occlusion  could  not  be  determined 
in  the  usual  way.  On  X-ray  examination,  the  whistle  was  found  at  the 
junction  of  the  small  and  large  intestine.  On  the  third  day  the  whistle 
was  passed.  A  boy,  of  12,  had  symptoms  of  obstruction  and  was  in  a 
serious  condition.  The  first  diagnosis  was  one  of  invagination  at  the 
lower  portion  of  the  ileuin.  On  X-ray  examination  an  obstruction  was 
found  in  the  small  intestine  under  the  umbilicus.  Laparotomy  was 
performed,  and  the  obstruction  was  discovered  to  be  caused  by  a  small 
wooden  whistle.  The  author  has  produced  artificial  obstruction  in  dogs, 
and  then  traced  a  specially  prepared  pill  to  the  point  of  obstruction  by 
means  of  the  X-rays.  The  diagnosis  in  such  cases  was  verified. 

I  believe  that  the  exact  location  of  the  obstruction  or  of  a  particular 
portion  of  the  intestine  cannot  be  determined  because  of  the  superimposi- 
tion  of  the  coils  of  the  intestines ;  but  an  approximate  location  in  the 
abdominal  cavity  can  be  ascertained  by  the  direction  of  the  passage 
traversed  by  a  specially  prepared  opaque  pill. 

An  important  case  coming  under  my  care  was  that  of  a  man,  42  years 
old,  suffering  with  symptoms  of  intestinal  obstruction.  An  X-ray  exami- 
nation was  conducted,  revealing  a  large-sized  enterolith.  The  seat  of 
obstruction  was  at  the  ileo-caecal  valve.  An  operation  was  performed  and 
the  obstructing  mass  removed.  Three  years  prior  to  this,  the  patient  had 
been  a  sufferer  from  biliary  calculi,  but  refused  to  undergo  an  operation 
at  that  time.  It  is  very  likely  that  this  intestinal  calculus  was  primarily 
a  biliary  calculus  which  passed  into  the  intestines  and  there  remained 
for  a  period  of  three  years,  gradually  becoming  larger  and  larger.  The 
exterior  of  this  stone  was  uniformly  softened,  while  the  centre  was  ex- 
tremely dense. 

Following  a  biliary  colic,  it  is  always  advisable  to  ascertain,  by  an 
X-ray  examination,  if  calculi  have  been  passed  into  the  intestinal  tract. 

Rrctal  Imperf oration. — The  following  case  is  illustrative  of  this  con- 
dition. A  child  when  born  was  observed  to  have  an  imperforate  anus, 
with  an  absence  of  rectal  tract.  A  consulting  surgeon  suggested  an 
inguinal  colostomy.  The  child  lived  with  this  annoying  condition  for 
twelve  years.  It  was  then  decided  to  try  further  surgical  means.  I 
proceeded  to  examine  the  case,  as  follows  :  Into  the  rectum  through  the 
artificial  anus,  I  injected  an  emulsion  of  bismuth  subnitrate,  at  the  same 
time  passing  a  steel  sound  through  the  anus  to  the  point  of  obstruction 
at  the  lower  end  of  the  rectum.  A  skiagram  proved  the  obstruction  to 

1  Medical  News,  Oct.  5,  1901. 


: : ;  I •  •  ELECTRO-TH I •:  I ;  A  I '  KUTICS. 

be  two  inches  in  length.  The  upper  part  of  the  rectum  was  anastomosed 
to  the  iletiin,  after  first  removing  the  coccyx.  For  ten  subsequent  days 
the  fiecal  material  passed  through  the  newly  constructed  channel.1 

Abdominal  New  Groicths. — The  recognition  of  neoplasms  located  in 
the  abdominal  cavity,  by  means  of  the  X-rays,  is  a  rather  difficult  task.  If 
the  tumor  is  dense,  it  may  cast  a  shadow  upon  the  screen  :  if  more  or  less 
soft,  no  shadow  will  be  cast.  These  pathological  masses  are  frequently 
recognized  by  their  effects  upon  adjacent  structures,  as  in  a  displacement 
of  the  diaphragm,  liver,  etc.  I  have  made  numerous  examinations  of 
suspected  carcinomata  of  the  stomach,  some  of  the  results  being  favor- 
able, though  the  vast  majority  proved  unsatisfactory.  It  must  not  be 
forgotten  that  in  carcinomata  of  the  pylorus  there  is  some  interference 
with  the  movement  of  the  diaphragm  on  that  side,  the  latter  not  de- 
scending to  so  low  a  point  as  in  the  normal. 

E.  LIVER. 

The  correct  general  outline  of  the  liver  may  be  obtained  by  combin- 
ing a  fluoroscopical  and  physical  examination.  The  upper  or  convex 
border  of  this  organ  can  very  readily  be  ascertained  by  the  fluorescent 
screen,  while  the  lower  and  concave  border  is  best  outlined  by  palpation 
and  percussion.  Echiuococcus  cysts,  when  located  in  the  immediate 
vicinity  of  the  upper  border,  may  be  easily  diagnosticated  by  this  means. 
When  examining  this  organ,  it  is  always  advisable  to  have  the  adjacent 
portion  of  the  stomach  and  intestines  filled  with  air  or  gas,  so  as  to  more 
readily  define  the  lower  border  of  the  liver.  A  skiagraphic  examina- 
tion, especially  in  adult  cases,  is  very  unsatisfactory.  In  young  children 
better  results  are  obtained. 

Biliary  Calculi. — The  results  of  a  skiagraphic  examination  in  this 
condition  depend  to  a  very  large  extent  upon  the  chemical  composition 
of  the  calculus.  Upon  the  negative,  only  a  very  light  shadow  of  the 
stone  is  thrown  and  can,  by  a  very  careful  examination,  be  seen  only 
with  difficulty,  even  though  it  is  of  rather  large  size.  Occasionally  large 
calculi  can  even  be  detected  in  the  heptic  duct.  Calculi  composed  of 
bilirubin  and  certain  other  substances  are  not  very  permeable  to  the  rays. 
Those  calculi  consisting  of  cholesterin,  being  largely  composed  of  calcium 
salts,  show  more  distinctly  on  the  negative  than  do  the  others.  Early 
experiments  upon  gall-stones  have  been  reported  by  Neisser,  Goodspeed, 
and  Cattell.1 

A  fluoroscopic  examination  for  biliary  calculi  is  thoroughly  unsatis- 
factory, and  until  a  skiagram  is  taken  no  absolute  diagnosis  should  be 
rendered.  The  method  I  employ  is  as  follows  :  The  patient  rests  upon 
the  table  (upon  his  back)  with  the  head-end  raised  and  the  foot-end 

1  For  full  report  of  this  case  see  Hemmeter,  "  Diseases  of  the  Intestines,"  vol.  ii. 
'Medical  News,  Feb.  15,  1896. 


DISEASES  OF  THE  ABDOMINAL  ORGANS.  347 

depressed,  the  whole  top  of  the  table  slanting  in  a  position  of  45°.  The 
abdomen  should  be  bared  of  clothing  and  lightly  bandaged,  in  order  to 
lessen  the  peristaltic  and  respiratory  movements.  The  patient  is  slightly 
turned  toward  the  right  side.  A  sensitive  plate  of  proper  dimensions  is 
firmly  fixed  by  a  clarnp  and  bracket  to  a  stand  in  front  of  the  affected 
region.  A  tube  of  the  highest  penetrative  power  is  placed  under  the 
table,  with  the  target  pointing  in  the  direction  of  the  gall-bladder,  or  the 
patient  may  be  placed  in  the  ventral  position,  with  the  tube  above.  The 
shoulders  should  be  elevated,  so  as  to  bring  the  shadow  of  the  gall- 
bladder outside  of  the  shadow  of  the  lower  lobe  of  the  liver.  The  time 
of  exposure  varies,  depending  upou  the  thickness  of  the  part  to  be 
traversed  by  the  rays. 

The  presence  of  calculi  is  very  difficult  to  detect,  because  their 
chemical  composition  allows  the  passage  of  the  rays,  they  being  largely 
composed  of  the  hydrocarbon  cholesterin.  Moreover,  the  shadow  of  the 
calculus  is  very  liable  to  be  obscured  by  the  shadow  of  the  contents  of  the 
gall-bladder.  When  the  stone  finds  its  way  into  the  intestine  and  there 
becomes  coated  with  calcium  phosphate  and  carbonate,  the  shadow  cast 
will  be  more  definite,  as  the  latter  salts  offer  a  resistance  to  the  passage  of 
the  rays. 

Dr.  C.  Thurston  Holland  *  reports  the  following  case :  "A  woman, 
of  45,  had  two  attacks  of  severe  abdominal  pain,  one  accompanied  by 
slight  jaundice.  A  tumor  was  discovered  in  the  right  abdomen  and 
diagnosed  as  a  distended  gall-bladder. 

"  The  radiograph  was  taken  with  a  12-inch  coil  and  a  mercury  break. 
Current  employed  was  24  volts  and  10  amperes.  A  Cox  regulator  tube 
was  used  with  a  spark-gap  of  3  inches  (7.5  cm.)  and  through  a  pressure- 
tube  apparatus  designed  by  the  author.  An  exposure  of  two  minutes 
was  given.  The  stones,  each  three-quarters  inch  (2  cm.)  long,  were 
lying  end  to  end,  from  before  backward,  and  cast  annular  shadows  with 
the  patient  lying  with  the  abdomen  downward  on  the  plate.  A  second 
radiograph,  taken  with  the  woman  on  her  back,  also  showed  the  same  an- 
nular shadow,  but,  the  stones  being  further  from  the  plate,  the  shadow 
was  larger  and  not  so  well  defined.  A  surgical  operation  disclosed  two 
stones  of  the  usual  type  ;  one  weighed  100  grains  (6.4  grains),  the  other 
113  grains  (7  grams),  which  were  composed  of  concentric  laminse  of  bile- 
pigment  and  cholesteriu.  Calcium  was  present,  but  greater  in  quantity 
at  the  periphery,  where  the  stones  were  much  harder. 

"The  success  attained  in  this  case  was  due  to  the  presence  of  lime- 
salts,  and  to  the  employment  of  a  pressure-tube  apparatus  which  fixed  the 
part  and  cut  off  all  except  a  small  central  stream  of  X-rays,  and  most  of 
the  secondary  rays,  and  thus  prevented  fogging  of  the  plate  and  blurring 
of  the  shadows." 

1  Archives  of  the  Rontgen  Ray,  Feb.  1906,  p.  241. 


348  ELECTROTHERAPEUTICS. 

Dr.  Carl  Beck  '  made  97  skiagraphs  of  28  suspected  cases  of  cholelithi- 
asis ;  in  19  of  those  cases  the  presence  of  biliary  calculi  was  ascertained 
by  operation.  In  only  two  of  these  19  cases  was  he  able  to  obtain 
shadows  on  the  plates.  Later,  had  good  skiagraphs  of  gall-stones  ex- 
hibited at  a  meeting  of  the  Academy  of  Xew  York,  held  in  January,  1901. 

For  cutting  off  the  secondary  rays  I  think  the  compression  dia- 
phragm is  at  times  useful.  I  have  had  cases  where  the  plates  showed 
shadows  of  the  distended  gall-bladder,  but  not  of  the  calculi,  because 
fluid  offers  great  resistance  to  the  passage  of  the  rays.  In  most  instances 
the  shadow  will  be  too  low  when  the  calculi  have  passed  into  the  intestine. 

Recently,  at  the  Philadelphia  Hospital,  I  was  asked  to  take  a  skia- 
graph of  a  very  emaciated  patient.  I  found  the  shadows  of  two  renal 
calculi  in  the  left  kidney,  and  a  round,  small  stone  under  the  twelfth  rib, 
on  the  right  side,  and  a  large  one  in  the  pelvis  of  the  right  kidney.  The 
latter  was  subsequently  removed,  but  the  former  defied  surgical  detection ; 
although  I  am  sure  the  round  shadow  was  that  of  a  biliary  calculus. 

I  do  not  think  the  fluoroscope  is  as  reliable  in  these  cases  as  is  the 
skiagraph,  provided  that  in  the  latter  the  time  of  exposure  is  correct 
and  the  subject  is  a  suitable  one.  I  never  have  had  a  case  of  this  kind 
where  the  diagnosis  was  solely  made  by  the  aid  of  X-rays  and  confirmed 
by  operation. 

F.  PANCREAS. 

On  account  of  its  peculiar  anatomical  situation,  this  organ  cannot  be 
easily  recognized  by  an  X-ray  examination.  In  one  instance  I  was  able 
to  obtain  a  shadow  of  this  organ  on  a  skiagram.  The  patient  was  unusu- 
ally emaciated,  and  from  the  clinical  signs  and  symptoms,  a  diagnosis  of 
carcinoma  of  the  pancreas  had  been  made.  The  patient  was  prepared  as 
usual,  and  subjected  first  to  a  fluoroscopic  and  then  to  a  skiagraphic 
examination ;  a  very  faint  shadow  was  discoverable,  superimposed  upon 
the  one  produced  by  the  stomach.  Since  then,  I  have  at  frequent  inter- 
vals tried  to  make  similar  examinations  on  different  subjects,  but  have 
never  succeeded  in  repeating  or  reproducing  what  then  was  considered  a 
rather  satisfactory  image  of  this  organ.  In  this  instance  I  distended  the 
stomach  with  air  in  order  to  allow  as  clear  a  field  for  this  organ  as  possi- 
ble. I  am  of  the  opinion  that  this  fairly  good  result  was  due  to  a  peculiar 
abnormal  principle  which  is  opaque  to  the  rays,  and  whose  nature  thus 
far  has  not  been  determined. 

G.  SPLEEN. 

This  organ  is  easily  shown  in  children  by  means  of  the  fluorescent 
screen.  In  adults  the  skiagraph  only  is  satisfactory.  The  patient  is  best 
examined  in  the  recumbent  position,  being  slightly  turned  toward  the  left 

1  New  York  Medical  Journal,  January  20,  1900. 


DISEASES  OF  THE  ABDOMINAL  ORGANS.  349 

side.  The  sensitive  plate  is  placed  in  front  of  the  patient  in  the  region  of 
this  organ,  with  the  tube  below  or  behind.  In  those  who  are  corpulent, 
it  is  best  to  place  the  patient  in  the  prone  position  with  the  plate  beneath 
and  the  tube  above. 

Just  prior  to  the  examination,  the  large  intestine  should  be  distended 
with  air.  This  procedure  will  serve  to  displace  all  of  the  adjacent  organs, 
and  at  the  same  time  permit  the  production  of  contrast  between  the 
lower  edge  of  the  spleen  and  the  neighboring  light  area  produced  by 
these  distended  organs.  The  upper  border  is  in  relation  with  the 
diaphragm,  and,  in  order  to  avoid  the  blurring  of  the  image,  the 
rays  should  be  permitted  to  emanate  from  the  tube  only  during  inter- 
vals when  the  patient  has  ceased  breathing.  The  screen  examination 
of  the  spleen  in  a  child  demonstrates  the  fact  that  the  anterior  border 
moves  slightly  more  than  the  posterior,  as  though  this  organ  were  turning 
on  its  long  axis. 

II.  Genito-Urinary  System. 

The  great  strides  made  in  surgery  and  surgical  bacteriology  within 
the  past  twenty  years  have  effected  a  complete  change  in  the  conceptions, 
the  prognoses,  and  the  treatment  of  many  surgical  affections.  Neverthe- 
less, prior  to  Rontgen's  discovery  positive  diagnoses  of  many  diseased 
conditions  were  manifestly  impossible.  The  truth  of  this  statement  gains 
added  support  in  the  genito-uriuary  field.  Many  of  the  pathological 
states  of  the  kidney  could  be  ascertained  only  by  cutting  down  upon 
that  organ,  especially  in  suspected  cases  of  calculi,  displaced  kidney, 
hydrouephrosis,  pyonephrosis,  etc.,  frequently  forcing  upon  the  surgeon 
the  serious  embarrassment  of  operating  upon  some  distant  organ,  wherein 
pain  was  experienced  by  the  patient,  the  result  of  reflex  irritation.  In 
the  same  manner  invaluable  assistance  has  been  lent  by  this  new  aid  in 
the  diagnoses,  in  many  of  the  more  obscure  diseases  and  affections  of 
the  ureters,  the  bladder,  and  the  prostate  gland. 

The  shadows  of  the  kidneys  are  most  difficult  to  show  on  the  negative. 
The  upper  portion  of  the  right  kidney  presents  an  added  obstacle  in  the 
superimposed  shadow  cast  by  the  liver.  The  affection  of  the  kidney 
most  frequently  brought  to  the  attention  of  the  skiagrapher  is  that  of 
suspected  calculus. 

A.  ORDINARY  METHODS. 

It  is  common  experience  that  a  case  of  renal  calculus  will  be  evi- 
denced by  a  few  of  the  classical  signs  and  symptoms  which  not  infre- 
quently confuse  the  mind  of  the  diagnostician.  Thus,  Henry  Morris, 
the  eminent  English  surgeon,  found  renal  calculi  in  two-thirds  of  his 
suspected  cases.  Brewer1  mentions  two  instances  where  distinguished 

1  Annals  of  Surgery,  May,  1901. 


350  ELECTROTHERAPEUTICS. 

surgeons  diagnosed  stone  in  the  kidney  as  cases  of  appendicitis. 
Bevan  and  Franks  made  the  same  error,  the  former  suspected  a  case  of 
appendicitis,  and  the  latter  ovarian  disease.  Jacobson1  mentions  at 
length  the  differential  diagnosis  between  incipient  spinal  caries  and 
renal  calculi. 

Prior  to  the  discovery  of  the  X-rays,  the  most  advanced  studies  in 
kidney  affections  were  due  to  ureteral  catheterization,  introduced  by 
Howard  A.  Kelly,  of  Baltimore,  and  to  Harris's  invention  of  the  segre- 
gator,  for  drawing  off  separate  urines  from  each  kidney.  The  chief  clini- 
cal aids  may  be  stated  as  follows : 

General  symptoms,  chemical,  macroscopic,  and  microscopic  examina- 
tions of  the  urine  with  the  addition  of  the  centrifuge,  percussion  over  the 
affected  side,  the  ureteral  catheter  and  sound,  inspection  of  the  bladder 
and  ureteral  orifices,  and  the  segregator.  With  the  possible  exception  of 
the  actual  finding  of  a  stone  in  the  urine,  we  are  not  absolutely  convinced 
whether  we  are  to  deal  with  a  nephritic  calculus,  if  there  is  one  or  many, 
if  it  is  in  the  ureter,  or  if  one  calculus  is  in  the  ureter  and  another  in 
the  kidney.  If  upon  exploration  only  one  stone  is  found,  it  is  not 
conclusive  evidence  that  others  are  not  present,  either  in  the  ureter  or 
some  other  part  of  the  kidney. 

B.  PENETRABILITY  OF  CALCULI. 

The  most  useful  and  accurate  method  thus  far  advanced  for  the 
detection  of  renal  calculi  is  by  means  of  the  X-rays.  Chapius  and 
Chauvel,*  in  Paris,  were  the  first  investigators  to  study  renal  calculi 
by  the  aid  of  the  X-rays.  They  mention  that  calculi,  whose  chemical 
structure  is  uric  acid,  urates,  or  phosphates,  cast  shadows  slightly  less 
opaque  to  the  rays  than  do  compact  bones.  As  the  kidney  substance 
is  not  so  easily  penetrated  by  the  rays  as  muscular  tissue,  it  would 
be  natural  to  infer  that  the  negative  would  show  a  lighter  shadow  than 
the  adjacent  tissue  which  is  more  penetrable  by  the  rays.  Dr.  Mac- 
intyre,3  of  Glasgow,  also  made  early  and  successful  investigations  on 
renal  calculi. 

Dr.  James  Swain,4  of  Bristol,  was  the  first  to  detect  the  different 
degrees  of  penetrability  of  different  calculi.  His  method  of  investi- 
gation was  as  follows  :  On  a  sensitive  plate  he  placed  different  calculi 
of  the  same  dimensions,  exposing  them  for  periods  of  one,  two,  four, 
eight,  and  sixteen  minutes.  He  early  observed  that  "the  more  dense 
the  object  the  deeper  was  the  resulting  shadow,"  and  that  the  law  first 
laid  down  by  Rontgen  was  not  true  of  different  calculi.  If  tabulated 

1  British  Medical  Journal,  January,  1900. 
'Academic  cle  Mldecine,  21,  iv.,  1896. 
"Lancet,  July  11,1896. 
4  Bristol  Medico-Chirurgical  Journal,  March,  1897. 


DISEASES  OF  THE  ABDOMINAL  ORGANS.  351 

in  the  order  of  their  highest  specific  gravity,  their  greatest  permeability 
to  the  rays,  and  their  greatest  density  of  shadow,  the  results  attained  are 
as  follows : 

SPECIFIC  GRAVITY.  PERMEABILITY  TO  THE  RAYS.  DENSITY  OF  SHADOW. 

1.  Oxalate  of  calcium.             1.  Biliary.  1.  Oxalate  of  calcium. 

2.  Uric  acid.                             2.  Uric  acid.  2.  Phosphatic. 

3.  Phosphatic.                          3.  Phosphatic.  3.  Uric  acid. 

4.  Biliary.                                 4.  Calcium  Oxalate.  4.  Biliary. 

Dr.  Swain  exposed  one  calculus  of  each  type  with  a  section  of  rib 
and  a  piece  of  kidney.  An  increased  time  of  exposure  produced  a 
fainter  shadow,  so  that  at  the  end  of  the  ''sixteenth  minute,"  the  calcium 
oxalate  and  phosphatic  calculi,  with  a  faint  trace  of  rib,  showed  on  the 
negative.  The  conclusions  reached  from  these  experiments  are  that  the 
shorter  exposures  are  better  than  long  exposures,  also  that  calcium 
oxalate  and  the  phosphatic  calculi  show  most  plainly. 

If  the  exposures  are  too  prolonged,  the  less  dense  calculi  will  pro- 
duce no  shadow.  Likewise  a  calculus  of  uric  acid  gives  a  fainter  shadow 
than  the  rib,  and  in  an  eight  minute  exposure  much  less  of  a  shadow  than 
that  of  a  rib  covered  partially  with  kidney.  Thus  we  conclude  that  a 
calculus  of  uric  acid  is  difficult  of  detection. 

The  most  accurate  method  is  that  advanced  by  Eontgen.  The  many 
errors  made  in  the  diagnosis  or  elimination  of  renal  calculi  were  all  due 
to  a  faulty  teohuic,  to  an  incorrect  development  of  the  plate,  or  to  an 
erroneous  interpretation  of  the  negative.  It  is  imperative  to  produce  a 
skiagram  that  has  detailed  shadows  of  tissues  less  opaque  than  the  least 
opaque  calculus. 

By  means  of  the  X-rays  we  are  enabled  to  diagnose  hypertrophy, 
atrophy,  displacement,  tumors,  hydronephrosis,  pyonephrosis,  and  peri- 
nephritic  abscess.  Hypertrophy  is  a  condition  which  is  always  unilateral, 
and,  by  comparison  with  the  kidney  of  the  opposite  side,  is  readily  diag- 
nosticated. The  above  mentioned  conditions,  however,  can  only  be 
demonstrated  in  those  subjects  not  too  corpulent,  when  the  exposure  has 
been  sufficiently  long,  and  when  the  exposed  negative  has  been  properly 
produced  by  the  developing  process.  The  margin  of  the  hypertrophied 
kidney  is  clear  and  sharp.  If  this  sharp  margin  is  irregular  in  any  of 
its  part,  the  examiner  has  found  a  neoplasm  springing  from  the  cortical 
area.  Atrophy  of  the  kidney  is  more  difficult  of  diagnosis.  The  most 
usual  cause  is  the  existence  of  a  calculus. 

Displacement  of  the  kidney  is  a  common  affection,  its  occurrence 
being  indicated  by  a  knowledge  of  its  normal  relations  and  by  a  com- 
parison with  the  shadow  produced  by  the  abnormal  position.  Perine- 
phritic  abscess  can  also  be  diagnosticated  by  the  rays.  The  conditions 
favorable  for  best  results  are  found  in  patients  of  slight  build,  and  when 
the  intestinal  canal  has  been  thoroughly  evacuated. 


352  ELECTRO-THERAPEUTICS. 

In  hydronephrosis  and  pyonephrosis,  a  shadow  showing  involvement 
of  the  pelvis  of  the  kidney  may  be  observed.  This  condition  is  more 
readily  diagnosticated  from  a  good  negative  than  is  a  periuephritic 
abscess. 

Cases  of  gonorrhoea,  with  pus  in  the  region  of  the  kidney,  have  been 
diagnosed  with  the  X-rays;  the  skiagram  showing  an  irregular  mass  on 
the  convex  border  of  the  shadow  produced  by  the  kidney,  the  shadow 
of  which  is  denser  than  that  obtained  from  the  normal  kidney*  itself. 

C.  TECHNIC  OF  RENAL  SKIAGRAPHY. 

When  renal  calculi  cannot  be  diagnosticated  by  skiagraphy,  the 
chief  causes  will  be  found  to  be  under-  or  over-exposure  and  improper 
development  of  the  exposed  plate,  or  because  the  tube  lacks  the  necessary 
high  penetrative  power. 

Preparation  of  Patient. — In  taking  a  skiagram  see  that  the  patient  is 
briskly  purged,  and  that  he  abstains  from  all  food  for  at  least  24  hours 
prior  to  the  time  of  exposure ;  in  the  interval,  give  him  a  high  enema. 
The  bladder  should  be  emptied  just  before  the  time  of  taking  the 
picture  ;  if  this  be  impossible  he  should  be  catheterized.  The  patient  is 
placed  in  the  recumbent  posture,  and  the  knees  flexed,  so  that  the  normal 
lumbar  curve  will  come  in  closer  contact  with  the  plate.  Two  plates  of 
sufficient  size  to  include  both  kidneys  should  be  placed  on  top  of  one 
another,  and  protected  by  a  celluloid  cover,  in  order  to  prevent  injury 
from  excretions.  The  upper  edge  of  the  plate  should  correspond  to  the 
position  of  the  tenth  rib,  and  the  lower  edge  to  the  superior  part  of  the 
sacrum.  This  will  include  part  of  the  ureters  at  the  lower  end  of  the 
plate.  The  tube  should  be  of  the  highest  penetrative  power,  so  as  to 
lessen  the  time  of  exposure.  When  both  kidneys  are  to  be  skiagraphed 
the  tube  should  be  placed  in  the  median  line  above  the  patient,  and  at 
a  level  corresponding  to  the  position  of  the  pelvis  of  the  kidney. 

If  only  one  kidney  is  to  be  skiagraphed,  use  a  smaller  plate,  placing 
the  tube  in  front  of  the  patient,  with  the  target  pointing  to  the  centre  of 
the  kidney.  As  respiratory  movements  interfere  with  the  production  of 
an  accurate  skiagram,  the  whole  abdomen  should  be  bandaged  as  tightly 
as  possible.  Some  examiners  prefer  the  patient  holding  his  breath 
during  exposure,  but  I  have  encountered  some  difficulties  in  attempting 
to  carry  out  this  method.  For  skiagraphing  the  renal  organs,!  always 
use  the  Wehnelt  interrupter. 

C.  C.  Slaberia  and  A.  P.  Slaberia,1  of  Barcelona,  recommend  the  use 
of  a  moderately  hard  tube  (except  in  cases  of  very  stout  patients,  when 
a  hard  tube  should  be  employed)  and  a  long  exposure,  varying  from  three 
to  six  minutes  in  children,  as  much  as  thirty  minutes  in  adults,  and  up 
to  sixty-five  minutes  in  very  stout  persons.  They  do  not  employ  an 

1  Fortechritte  a.  d.  Geb.  der  Rontgenstrahlen,  Band  v.,  Hefte  2,  3. 


DISEASES  OP  THE  ABDOMINAL  ORGANS.  353 

electron-tie  break,  nor  have  they  seen  any  erythema  or  other  injurious 
effects,  although  in  one  instance  the  patient  was  skiagraphed  seven  times. 
Except  in  the  case  of  a  displaced  or  very  movable  kidney,  they  advise 
the  dorsal  position  of  the  patient.  Despite  some  advantages,  they  con- 
sider the  ventral  position  inadvisable  because  of  the  increased  distance 
of  the  kidney  from  the  plate.  Dr.  Charles  L.  Leonard,  of  this  city,  was 
the  first  to  advocate  a  low- vacuum  tube,  with  a  spark-gap  of  li  to  2  inches, 
(4-5  cm.)  which  is  self  regulating,  and  which  will  give  a  large  volume  of 
low- vacuum  Rontgen  discharge.  He  formulates  this  axiom,  "  that  in  a 
negative  possessing  a  differentiation  in  the  shadow  of  tissues  less  dense 
than  the  least  dense  calculus,  no  calculus  can  escape  detection."  Per- 
sonally I  agree  with  Shenton  and  those  other  skiagraphers  who  advocate 
the  high- vacuum  tube  with  a  short  exposure.  The  latter  is  advantageous 
in  taking  negatives  of  suspected  calculi,  for  these  can  be  applied  while 
the  patient  "  holds  his  breath,"  thus  avoiding  diaphragmatic  movements. 
I  always  make  several  short  exposures  when  skiagraphing  this  region.  I 
believe  there  is  less  likelihood  of  penetrating  the  calculus  with  the  high 
tube  and  short  exposure,  than  with  a  softer  tube  and  a  longer  exposure. 
I  cannot  advise  the  use  of  the  intensifying  screen,  because  of  the  gran- 
ularity presented  on  the  negative  ;  neither  do  I  recommend  the  compres- 
sion diaphragm,  as  we  do  not  know  where  to  apply  the  latter,  as  it  covers 
only  a  small  area  at  a  time,  and  thus  prevents  comparison  between  the 
abnormal  and  the  corresponding  normal  part.  Dr.  Joseph  F.  Smith,  in 
his  paper  "The  Rontgen  Ray  Diagnosis  of  Renal  Calculus,"1  remarks  : 

"In  1899,  Abbe  collected  from  literature  and  tabulated  twenty-five 
cases  in  which  a  positive  diagnosis  had  been  made  by  the  X-ray  and  later 
confirmed  by  operation.  To  this  list  of  twenty-five  he  added  two  cases 
of  his  own,  making  twenty-seven  cases  reported  up  to  that  time.  These 
twenty-seven  cases  are  arranged  by  years  as  follows :  1896.  Macintyre, 
of  Glasgow,  reported  the  first  skiagraph  of  a  stone  taken  in  the  body. 
Swain,  of  Bristol,  reported  a  case.  1897.  Gurl,  Nuremberg ;  Fenwick, 
England  ;  Thyne,  Australia.  1898.  Bevan,  Chicago  ;  McArthur,  Chicago  ; 
Lauenstein,  Germany ;  Alsburg,  Germany ;  Martin,  England  ;  Taylor, 
England ;  Fenwick,  England ;  Leonard,  Philadelphia,  eight  cases ; 
McBurney,  New  York;  Abbe,  Xew  York,  two  cases.  1899.  Wagner, 
Germany,  two  cases." 

Speaking  upon  the  probable  errors  likely  to  arise  in  cases  of  ne- 
phritic calculi,  Dr.  Chas.  L.  Leonard,  one  of  the  greatest  authorities  on  this 
subject  in  America,  says:2  "  The  absolute  negative  and  positive  diagnosis 
of  calculous  nephritis  and  ureteritis  can  be  made  with  an  error  of  less 
than  3  per  cent.  A  statistical  study  of  the  320  cases  examined  shows 
that  calculi  have  been  found  in  93  cases,  or  a  little  less  than  a  third 
of  the  cases  examined.  In  many  of  the  cases,  in  which  a  negative  or 

'Annals  of  Surgery,  May,  1904.  2  American  Medicine,  June  4,  1904. 


354  ELECTRO-THEEAPEUTICS. 

exclusion  diagnosis  was  rendered,  the  patients  had  such  slight  symptoms 
as  to  render  the  presence  of  calculi  possible,  but  not  probable.  In  47 
cases  the  symptoms  demanded  operative  intervention,  and  in  all  but  one 
the  accuracy  of  a  negative  diagnosis  was  proved  by  the  operation,  and  no 
calculi  were  found.  In  many  of  the  cases  of  negative  diagnosis  in  which 
there  was  no  operation,  the  subsequent  development  of  other  conditions 
showed  that  the  diagnosis  had  been  correct.  In  three  cases  of  negative 
diagnosis,  small  calculi,  that  had  escaped  detection,  were  subsequently 
passed.  Thus,  there  has  been  a  total  error  of  but  four  cases  in  the 
negative  diagnoses,  one  due  to  defective  technic,  and  the  others  to 
inaccurate  reading  of  the  plates." 

Bevan  l  published  a  paper  in  the  Annals  of  Surgery,  reporting  13  or 
14  cases,  and  claimed  that  the  X-ray  as  a  means  of  diagnosis  was  to  be 
relied  on  to  a  greater  extent  in  cases  of  kidney  stone  than  any  other  means 
at  our  disposal.  He  thinks  the  best  exposition  of  this  entire  work  is  to 
be  found  in  "Beitrage  fiir  Chirurgie,"  from  the  pens  of  Kummel  and 
Eumpel.  Kummel  takes  the  position  of  Leonard  and  Bevan,  and  pre- 
sents practically  these  conclusions,  that  the  X-ray,  properly  used,  will 
detect  a  stone  in  any  individual,  no  matter  how  thick,  or  of  what  chemical 
composition  ;  that  the  detection  of  the  stone  does  not  depend  so  much  on 
its  chemical  composition  or  the  thickness  of  the  individual,  as  it  does  on 
the  proper  use  of  the  X-rays. 

Kummel  and  Rumpel 2  report  a  series  of  eighteen  cases  diagnosed 
positively  by  the  X-rays,  all  of  which  were  subsequently  operated 
upon,  and  stone  extracted.  The  conclusions  drawn  from  their  work  are 
as  follows : 

"The  exact  diagnosis  of  kidney  stone  is  to  be  made  only  by  means 
of  the  Rontgen  procedure. 

"The  presence  of  a  kidney  stone,  whether  located  in  the  kidney 
substance,  the  calices,  or  in  the  ureter,  will  be  demonstrated  upon  the 
plate  in  every  case,  by  proper  application  of  the  Rontgen  method. 

"The  negative  result  of  the  Rontgen  method  after  repeated  attempts 
allows  of  the  exclusion  of  a  calculus. 

"The  demonstration  of  a  stone  shadow  upon  the  Rontgen  plate  is 
not  dependent  upon  the  size  and  chemical  composition  of  the  calculus, 
but  singly  and  alone  upon  the  technic  of  the  Rontgen  operator. 

"A  high  degree  of  corpulence  in  the  patient  may  render  the  demon- 
stration of  a  calculus  by  the  Rontgen  method  very  difficult,  but  in  general 
does  not  render  it  impossible. 

"In  every  case  of  nephrolithiasis  it  is  advisable  to  employ  the 
functional  methods  of  investigation,  since  they  show  us  by  combined 
application  (a)  whether  a  disturbance  of  the  whole  kidney  function  exists 

'Journal  of  the  American  Medical  Association,  March,  1905,  p.  1062. 
2  Beitrage  fiir  klin.  Chirurg.,  1903,  Band  xxxvii.,  Heft  2. 


DISEASES  OF  THE  ABDOMINAL  ORGANS.  355 

or  not,  (6)  whether  we  have  to  deal  with  a  double-sided  stone  formation 
or  other  coexisting  kidney  disorder,  or  whether  in  the  already  existing 
disorder  only  one  kidney  is  involved. 

"The  result  of  the  negative  Eontgeii  investigation  should  be  consid- 
ered in  connection  with  the  condition  of  the  clearness,  concentration,  and 
freezing-point  of  the  urine  obtained  by  means  of  the  ureteral  catheter." 

In  the  eighteen  cases  tabulated  by  Ruinpel.  two  of  the  stones  removed 
contained  only  triple  phosphates.  All  the  others  consisted  of  mixtures 
in  different  proportions  of  calcium  carbonate,  calcium  phosphate,  calcium 
oxalate,  and  uric  acid  or  urates.  Five  of  the  stones  consisted  largely  of 
calcium  oxalate,  fourteen  of  calcium  phosphate,  and  two  of  uric  acid. 
Of  the  two  stones  consisting  largely  of  uric  acid,  the  composition  of  the 
first  was  a  mixture  of  uric  acid  with  calcium  phosphate,  and  the  second, 
a  mixture  of  uric  acid  with  calcium  oxalate  and  phosphate. 

Errors  in  skiagraphiug  calculi  may  be  due  to  several  causes, — great 
density  of  the  parts,  as  in  very  stout  persons,  transparency  of  certain 
calculi,  as  of  the  uric  acid  type,  diminutive  size  of  the  stone,  faulty 
exposure,  faulty  development  of  plate,  or  any  defect  in  the  apparatus. 

I  am  in  accord  with  the  view  expressed  by  Dr.  Charles  L.  Leonard, 
that  a  positive  or  negative  diagnosis  of  a  urinary  calculus  should  be 
based  upon  the  findings  on  the  negative,  as  the  calculus  should  always  be 
detected,  if  the  negative  shows  a  shadow  of  the  least  dense  tissues.  On 
a  good  negative,  the  shadows  of  the  following  structures  should  be 
visible :  Shadows  of  the  lumbar  muscles,  the  transverse  processes  of 
the  vertebrae,  and  the  twelve  ribs. 

D.  URETERAL  CALCULI. 

These  are  difficult  to  skiagraph,  as  the  shadows  of  the  pelvic  bones 
superimpose  upon  the  shadow  of  the  calculi  in  the  lower  portion  of  the 
ureter. 

Of  the  93  cases  in  which  calculi  were  found,  Leonard  states  that 
there  were  four  in  which  calculi  were  present  in  the  kidney  and  ureter 
of  the  same  patient.  Including  these  cases,  33  renal  calculi  were  found 
and  64  ureteral. 

Tenny l  has  been  able  to  add  33  cases  of  ureteral  calculus  since  the 
publication  of  the  101  cases  collected  by  Schenck.2  The  location  of  these 
stones  has  been  in  a  general  way  in  one  of  three  places,  depending  on  the 
physiological  narrowing  of  the  ureter.  The  first  point  of  narrowing  is 
about  7  centimetres  down,  and  has  a  diameter  of  3.2  millimetres.  The 
second  is  just  above  or  below  the  brim  of  the  pelvis,  and  has  a  diameter 
of  4  millimetres,  and  the  third  is  at  a  point  just  above  the  bladder,  and 
has  a  diameter  of  2.5  millimetres.  The  number  of  stones  in  the  series  of 

1  Boston  Medical  and  Surgical  Journal,  Feb.  4,  1904. 
1  Johns  Hopkins  Hospital  Reports,  vol.  10. 


KLMTKO-THKKAI'EUTICS. 


:'>!  cases  caught  in  the  above  locations  corresponds  very  nicely  in  its 
diameters,  35  being  caught  in  the  first  isthmus.  18  in  the  second,  and  73 
in  the  third.  In  the  remaining  cases,  the  locations  were  not  given. 

On  the  left  side  of  the  ureter,  but  sometimes  on  the  right,  is  occa- 
sionally noted  a  sharp,  round,  white  shadow  corresponding  to  the  lower 


FIG.  190.— Reid's  apparatus  for  renal  skiagraphy. 

end  of  the  ureter.  This  is  caused  by  the  presence  of  a  phlebolith,  which 
must  not  be  mistaken  for  a  calculus.  Dr.  Russell  H.  Boggs,  of  Pitts- 
burg,  maintains  that  this  shadow  is  due  to  a  sesamoid  bone. 

E.  W.  H.  Shenton,1  of  London,  believes  that  the  flnoroscope  is  not 
sufficiently  used  in  examinations  for  renal  calculi.  He  advises  placing 
the  patient  in  a  horizontal  position,  face  downward,  with  the  arms  above 
the  head.  Efforts  should  be  made  to  make  the  lumbar  spine  straight, 
even  to  the  extent  of  placing  a  pillow  beneath  the  abdomen.  The  tube 
should  be  placed  beneath  the  patient  6  inches  (15  cm.)  from  the  abdomen, 
the  actual  distance  varying  according  to  the  conditions  of  the  tube  and 
the  size  of  the  patient.  The  screen  is  placed  upon  the  patient's  back. 

A  new  apparatus  for  skiagraphing  the  renal  region,  devised  by  Mr. 

'Archives  of  the  Rontgen  Ray,  March,  1902. 


DISEASES  OF  THE  ABDOMINAL  ORGANS. 


367 


A.  I).  Reid,  of  London  (Figs.  190  and  191),  and  manufactured  by  Harry 
"W.  Cox,  Ltd.,  of  London,  dispenses  with  the  use  of  compressors  and  is 
described  as  follows  :  The  patient  is  laid  upon  the  couch  and  an  air  cushion 
is  placed  under  the  part  to  be  radiographed.  The  plate  is  then  placed  on 
the  patient's  back  and  the  lead  base  with  the  upright  arm  is  attached  to  it 
When  the  patient  breathes  the 
lead  base  is  raised,  the  arm 
moves  the  lever  up  and  causes  it 
to  make  contact. 

This  contact  is  merely  a 
switch  introduced  into  the  pri- 
mary circuit  of  the  coil,  and 
consequently  when  it  is  closed 
the  current  is  enabled  to  pass, 
and  the  tube  flnoresces,  simul- 
taneously the  clock  shown  in 
the  illustrations  records  the 
length  of  the  exposure. 

It  is,  therefore,  obvious  that 
the  kidney — or  any  other  part 
of  the  body — must  always  be  in 
the  same  position  whenever  the 
tube  fluoresces. 

Dr.  Albers-Schonberg  be- 
lieves that  the  technic  in  renal 
skiagraphy  has  not  been  suffi- 
ciently studied.  Hard  tubes,  he 
argues,  should  not  be  used.  The 
shadows  thrown  by  the  last  ribs 
and  the  transverse  process  of  the 
first  lumbar  vertebrae  are  to  be 
taken  as  guides.  If  nothing  is 

seen  at  the  first  attempt,  it  should  not  be  concluded  that  the  result  is 
negative.  The  plate  should  be  intensified,  and  allowed  to  dry.  This 
brings  out  many  shadow  details,  previously  invisible.  To  obtain  the  best 
effects  the  plate  should  be  examined  at  a  distance  of  5  or  6  ft.  If  any 
specks  are  seen,  which  may  possibly  be  due  to  calculi,  another  exposure 
should  be  made  within  three  or  four  days.  In  any  case  of  doubt  a  sepa- 
ratr  exposure  should  be  made.  A  lead  pipe  with  an  opening  of  13  cm.  in 
diameter  is  placed  close  to  the  tube,  and  50  cm.  from  the  plate,  so  as 
to  cut  off  the  secondary  rays  and  obtain  a  well-defined  shadow.  (Figs. 
I'.'i'  and  193.)  My  time  of  exposure  in  renal  skiagraphy  depends  upon 
the  corpulence  of  the  patient,  and  the  degree  of  high  penetrative  power 
of  the  tube.  The  distance  of  the  target  from  the  plate  is  from  22  to  30 
inches  (55  to  75  cm. ). 


FIG.  191. — Clock  arrangement  and  break  of  the  same. 


358 


KI.i:<  TRO-THERAPEUTK  S. 


The  method  of  examination  of  the  kidney  by  the  X-rays,  when  the 
organ  is  outside  of  the  body  during  operation,  has  been  fully  described 
by  the  discoverer,  Mr.  Fenwick.1  It  consists  in  examining  the  kidney 
with  the  fluorescent  screen  after  the  organ  has  been  removed  as  far  as 
possible  from  the  abdominal  cavity.  In  some  cases,  he  says,  the  kidney 
cannot  be  displaced  out  far  enough  to  permit  of  a  screen  examination, 
due  to  insufficient  length  of  the  renal  vessels.  An  objection  to  this 
method  of  examination  is  that  the  surgeon  must  necessarily  remain 
in  darkness  for  at  least  ten  or  fifteen  minutes  before  he  will  be  able  to 
successfully  perform  a  screen  examination. 

F.  Voelcker  and  A.  Lichtenberg 2  describe  a  process  of  pyelography. 
The  ureter  is  catheterized,  and  the  instrument  is  advanced  to  the  renal 
pelvis.  A  5  per  cent,  solution  of  a  silver  salt  is  then  slowly  injected 
through  the  catheter. 

There  are  individual  variations  in  the  amount  of  fluid  which  the 
pelvis  will  tolerate :  in  one  instance  5  c.  c.  gave  rise  to  colicky  pains,  in 


Fio.  192.— Compression  diaphragm  of  Albers-Schonberg.    (Kny-Scheerer  Co.) 

others  50  to  60  c.  c.  could  be  introduced.  The  shadow  cast  by  the  rays 
will  reveal  any  abnormality,  such  as  a  kinking,  bending,  constriction,  or 
dilatation  of  the  ureter. 

The  authors  employed  the  procedure  in  eleven  cases,  ten  being 
women  and  one  a  man.  In  four  of  their  cases,  their  efforts  were  unsuc- 
cessful. The  operation  is  not  very  painful,  but  is  more  easily  done  after 
an  injection  of  morphia. 

I  present  the  following  as  a  few  of  my  cases,  showing  the  value 
of  skiagraphy  in  determining  the  presence  of  nephritic  calculi  : 

In  the  Medico-Chirurgical  Hospital  in  1901,  I  examined  a  case  for 
Drs.  Rodman  and  West,  but  found  only  an  enlarged  kidney.  The 

1  The  British  Medical  Journal,  Oct.  16, 1897. 

*  Munch,  metl.  Woch.,  January  and  October,  1906. 


DISEASES  OF  THE  ABDOMINAL  ORGANS 


359 


operation  confirmed  the  diagnosis.  In  1900,  at  the  same  hospital,  I  skia- 
graphed  a  case  for  Dr.  Elwood  E.  Kirby,  and,  instead  of  a  calculus,  I 
found  a  collection  of  pus  ;  this  was  subsequently  confirmed  at  operation. 


FIG.  193.— The  same,  postero-anterior  view. 

For  several  years  I  made  an  annual  examination  of  a  patient,  under 
the  care  of  Dr.  Ernest  Laplace.  The  negative  showed  a  calculus  in  the 
pelvis  of  the  kidney,  which  was  subsequently  removed.  (Fig.  194.) 

In  a  case  under  the  care  of  Dr.  Alfred  Stengel,  I  found  a  calculus  in 
the  pelvis  of  the  kidney,  that  for  three  years  occasioned  an  unceasing 
dull  pain.  Dr.  Charles  H.  Frazier  removed  the  stone  at  the  University 
Hospital. 

At  the  Philadelphia  Hospital  in  1903,  I  skiagraphed  a  renal  calculus 
for  Dr.  J.  B.  Garnet,  which  was  successfully  removed. 

In  1904,  at  the  same  hospital,  Dr.  Ernest  Laplace  operated  for  a  sup- 
posed case  of  appendicitis.  After  the  operation  the  pain  continued,  and 
three  weeks  later  a  skiagram  revealed  a  calculus  in  the  kidney.  This  was 
removed,  and  the  patient  at  once  recovered. 

E.  THE  BLADDER. 

Examination  for  Calculi. —  The  preparation  required  is  the  same  as 
for  a  renal  examination,  and  in  addition  the  bladder  and  rectum  should 
be  emptied  just  prior  to  the  exposure.  The  patient  should  be  placed 
upon  the  table  in  the  ventral  position.  The  plate,  or  preferably  two, 


360  ELECTRO-THERAPEUTICS. 

well  protected,  should  be  laid  under  the  pelvis.  The  table  is  tilted  so 
that  the  head  will  be  much  lower  than  the  feet,  an  expedient  for  bringing 
the  calculus  as  much  above  the  pubis  as  possible,  thus  avoiding  super- 
imposition  of  the  shadows  of  the  calculus  and  the  bone.  The  tube  is 
placed  so  that  the  rays  will  be  parallel  with  the  sacrum  and  pass  through 
the  true  pelvis  without  causing  any  superimposition  of  the  shadows  on 
the  negative.  Skiagrams  produced  with  the  patient  lying  on  the  back 
have  been  very  satisfactory  in  my  experience,  especially  so  in  corpulent 
subjects,  by  placing  the  tube  above  the  umbilicus. 

In  Fig.  195  is  shown  the  skiagram  of  a  large  vesical  calculus.  At  a 
prominent  Philadelphia  hospital,  the  case  was  incorrectly  diagnosed  as 
an  enlargement  of  the  prostate.  The  patient  became  progressively  worse. 
and  as  a  victim  of  neurasthenia,  he  applied  to  the  Nervous  Department 
of  the  Medico-Chirurgical  Hospital,  1901.  Dr.  Ellwood  R.  Kirby  sug- 
gested the  wisdom  of  an  X-ray  examination,  when  the  large  calculus,  here 
shown,  was  found.  The  patient  was  operated  upon  and  made  a  perfect 
recovery. 

Englisch '  describes  a  total  of  405  cases  of  calculi  in  the  urethra  or 
diverticulum.  He  classifies  them  in  various  groups,  and  discusses  each 
in  turn.  The  stones  were  in  the  membranous  portion  in  149  instances, 
and  in  the  bulbous  urethra  in  68  cases. 

Closure  of  the  Bladder,  as  shown  Skiagraphically.  —  Leedhain-Greeu 2 
found  that,  whether  the  bladder  was  fully  distended  or  not,  the  outline 
of  the  organ  was  oval,  not  pyriform,  and  the  urethra  was  sharply  cut 
off  from  the  bladder  without  a  suggestion  of  a  bladder  neck.  There  are 
reasons,  therefore,  for  believing  that  the  sphincter  of  the  bladder  plays  a 
more  important  part  than  Finger  and  Guyon  credit  it  with,  and  that 
under  ordinary  circumstances  it  is  by  this  muscle  that  the  bladder  is 
closed,  whether  distended  or  not. 

F.  PROSTATIC  CALCULI. 

F.  Frank  Lydston 3  reports  that  a  farmer  aged  34  was  fallen  upon  by 
a  horse,  and  the  perineum  sustained  a  severe  blow.  Haematuria  followed, 
without  obstruction  of  the  urethra,  and  he  was  apparently  well  in  10 
days.  Six  months  later  there  was  difficulty  in  micturition ;  he  passed 
several  small  calculi,  and  has  done  so  at  intervals  since.  Examination 
revealed  an  apparent  calculus  at  the  bulbo- membranous  junction,  M  ith 
enlargement  of  the  prostate.  Operation  was  advised,  and  through  a  peri- 
neal  incision  a  calculus  weighing  720  grains  was  removed  from  the  pros- 
tate. Lydston  believes  that,  as  a  consequence  of  the  traumatic  stricture,  a 
certain  quantity  of  residual  urine  continually  remained  in  the  canal, 

1  Arch.  f.  klin.  Chir.,  Berlin,  1906,  p.  743. 
*  Archives  of  the  Rontgen  Ray,  May,  1906. 
5  Annals  of  Surgery,  March,  1904. 


FIG.  194.— Calculus  in  the  pelvis  of  the  right  kidney.    (Case  of  Dr.  Laplace.) 


DISEASES  OF  THE  ABDOMINAL  ORGANS.  361 

decomposition  followed,  with  the  formation  of  secondary  calculi.  The 
obstruction  caused  dilatation  of  the  prostatic  ducts,  small  secondary 
calculi  were  forced  into  the  latter,  and  one  of  these  became  enlarged, 
forming  a  nucleus  about  which  was  deposited  the  material  which 
resulted  in  the  formation  of  the  large  stone.  Stricture  of  the  urethra 
may  at  times  be  detected  by  injecting  bismuth  solution  and  then  taking 
a  skiagraph.  (For  biliary  calculi,  see  chapter  on  The  Alimentary 
System. ) 


CHAPTER  VI 
APPLICATION   IN  THE  SPECIALTIES. 

I.  Obstetrics  and  Gynaecology. 
OBSTETRICS. 

IN  radiographing  the  uterus  and  its  contents  much  difficulty  is 
encountered,  as  in  this  part  of  the  body  the  rays  will  have  to  penetrate 
many  thicknesses  of  tissues  ;  but,  if  the  abdominal  wall  is  not  too  fat.  fair 
results  may  be  expected.  Another  obstacle  is,  the  refusal  of  the  patient 
to  remain  in  a  constrained  position  for  a  sufficiently  long  time  to  obtain 
the  desired  results. 

The  distance  of  the  sensitive  plate  from  the  uterus,  the  movements 
of  the  foetus,  and  of  the  uterus  itself,  and  the  respiratory  movements  of 
the  mother,  are  obstacles  to  satisfactory  results. 

Pelvimetry.  —  A  new  process  of  pelvimetry  devised  by  Dr.  Henri 
Varnier1  demands  brief  attention.  When  a  radiograph  is  to  be  ob- 
tained, the  operator  arranges  the  X-ray  tube  at  a  short  distance  from 
the  part  to  be  radiographed,  usually  varying  from  16  to  24  inches  (40  to 
60  cm.).  The  result  is  that,  since  the  radiographic  negative  registers 
only  the  projected  shadows  of  the  object,  the  image  obtained  is  some- 
what larger  than  the  original,  at  least  for  all  the  parts  of  the  latter  not 
in  direct  contact  with  the  sensitive  plate. 

In  order  to  surmount  this  difficulty,  Dr.  Varnier  removed  his  source 
of  Eontgen  rays  to  a  distance  sufficient  to  permit  them  to  behave  practi- 
cally the  same  as  if  they  were  parallel.  He  has  shown  that  the  rays  may 
come  from  a  considerable  distance  and  the  ordinary  double  anode  tubes 
can  be  employed. 

With  a  coil  of  10  inches  (25  cm.)  spark  and  provided  with  a  Ducretet 
vibrator,  he  has  been  able,  in  an  exposure  of  ten  minutes  and  with  a  current 
of  10  amperes  at  26  volts,  to  obtain  the  outlines  of  a  dry  pelvis  upon  a 
photographic  plate  placed  at  a  distance  of  25  metres  from  the  Crookes 
tube,  and  in  an  exposure  of  20  minutes  the  same  outlines  were  obtained 
upon  a  plate  30  metres  distant.  It  is  usually  better  not  to  resort  to  such 
distances,  thus  obviating  long  exposures. 

At  a  distance  of  five  metres  the  usual  instruments  of  measurement 
do  not  show  any  difference  between  the  dimensions  exhibited  by  the 
object  and  the  radiograph.  For  ordinary  exigencies  a  distance  of  2.5 
metres  is  sufficient,  as  shown  in  the  following  measurements  by  Dr. 
Varnier  of  a  dry  pelvis.  The  error  found  is  of  the  same  nature  and 

'Scientific  American,  May  1,  1901. 
362 


APPLICATION  IX  THE  SPECIALTIES. 


363 


never  exceeds  5  millimetres, — /.  e.,  it  is  practically  nil.  The  modus 
operand!  is  extremely  simple.  The  Crookes  tube  is  placed  at  a  distance 
of  2.5  metres  (98  inches)  from  the  plate,  with  its  cathode  perpendicular 
to  the  long  axis  of  the  upper  brim  of  a  normal  pelvis,  taken  as  a  point 
of  observation. 

The  following  table  was  compiled  by  Dr.  Varnier  from  experiments 
and  measurements  with  a  dry  pelvis,  and  in  it  will  be  found  the  differ- 
ence between  the  dimensions  of  the  pelvis  itself  and  the  radiograph  : 


MEASUREMENTS  MADE 

DRY  PELVIS 

RADIOTYPE 

DIFFERENCE 

Maximum  transverse  diameter  

mm 
122 

114 
118 

103 
32 
235 
250 

inches 
=  4.803 

=  4.488 
=  4.1545 

=  4.055 
=  1.259 
=  9.281 
=  9.842 

mm 
126 

117 
121 

108 
33 
235 
250 

inches 
=  4.921 

=  4.606 
=  4.763 

=  4.251 
=  1.299 
=  9.251 
=  9.842 

mm. 
+3  = 

+3  = 
-1-3  = 

+5  = 
+  1  = 
+0  = 
+0  = 

inch 
+0.118 

+  0.118 
-fO.118 

+0.196 
4  0.040 

+  .0 
+  .0 

Antero-posterior  diameter  (the  only 

measure  up  to  the  present  )  .  .  .    . 

Left  oblique  diameter  

Transverse    bi-ischiatic   (  the    part 
farthest  from  the  plate  )  

Width    of    the    first    piece  of    the 
coccyx  

Distance  of  the  anterii  >r  and  posterior 
iliac  bones  

Transverse  diameter  of  the  greater 
pelvis  

Along  the  line  A  B  (Pig.  196)  taken  as  a  base,  he  arranges  in  his 
frame  a  40  x  50  centimetre  (15. 74  x  19. 6S  inch)  sensitized  plate.  The  dry 
pelvis  is  then  placed  in  pronation  (?.  <°.,  with  the  front  downward)  with 
the  line  of  crests  resting  upon  C  D  and  its  antero-posterior  diameter  in 
line  with  E  F. 

In  order  to  operate  upon  a  living  person,  it  suffices  to  replace  the 
dry  pelvis  by  the  subject  to  be  examined,  who  must  lie  so  that  the  pelvis 
will  assume  the  same  position.  By  using  the  data  given,  the  measure- 
ments may  be  accurately  obtained. 

The  patient  can  be  made  more  comfortable  by  employing  the 
author's  tube-holder  and  table,  placing  the  tube  under  the  table  and 
having  the  patient  assume  the  dorsal  decubitus  position  ;  often  the 
Trendelenburg  position  is  useful,  because  of  the  gravitation  of  the 
abdominal  contents  toward  the  diaphragm,  thereby  lessening  the 
obstruction  to  the  rays. 

Contreinoulins,1  of  Paris,  takes  two  skiagrams,  with  the  tube  in  two 

1  Bouchard,  "Traite  Radiologie  Medicale,"  p.  1010,  a  contributed  article  by 
M.  Kabre. 


ELECTKO-T 1 1EKAPEUTICS . 

different  positions,  without  disturbing  the  patient  or  altering  the  plane 
of  projection.     The  first  negative  is  taken  and  then  removed,  and   a 


FIG.  196.—  Varnler's  arrangement  for  radiography. 

second  plate  is  placed  in  the  same  position.  In  each  instance  the  normal 
point  of  incidence  is  indicated  on  the  skiagram.  A  tracing  of  the  salient 
points  is  made,  to  be  ultimately  transferred  to  a  zinc  plate.  Threads  are 
stretched  from  points  in  the  latter  by  which  the  two  cones  of  projection 


APPLICATION  IX  THE  SPECIALTIES.  365 

may  be  redrawn,  their  apices  corresponding  to  the  two  positions  of  the 
Crookes  tube.  The  intersection  of  these  cones  is  an  index  of  the  position 
and  size  of  the  pelvic  inlet. 

Stereo-skiagraphy  of  the  pelvis  is  the  best  method  to  employ  in 
pelvimetry  and  for  the  study  of  pelvic  deformities. 

The  data  given  in  the  above  table  are  those  used  in  the  special  radio- 
graphic  department  of  the  Baudelocque  clinic,  founded  by  Prof.  Pi  nan  I 
and  Dr.  Varnier. 

Williams1  says  :  ''In  order  to  determine  the  transverse  diameter  of 
the  superior  briui  of  the  pelvis,  the  following  method  has  been  devised 
by  me,  by  which  the  two  halves  of  the  pelvis  are  taken  separately,  but 
on  the  same  photographic  plate.  The  patient  lies  on  her  back  on  a 
stretcher,  with  the  plate  over  the  abdomen  and  the  inlet  of  the  pelvis 
about  parallel  with  the  plate.  When  the  right  side  of  the  pelvis  is  being 
taken,  the  left  half  of  the  plate  is  shielded  by  a  sheet  of  lead  placed 
under  the  plate.  The  tube  is  placed  by  means  of  a  plumb  line  as  nearly 
as  possible  directly  under  the  right  border  of  the  superior  brim  of  the 
pelvis,  in  the  line  of  the  pelvic  axis — 3  centimetres  to  the  right  of  the 
median  line.  If  the  tube  is  at  least  60  cm.  from  the  plate,  the  distortion 
in  the  photograph  will  not  be  great.  After  the  first  exposure  has  been 
made,  and  the  left  side  of  the  pelvis  is  to  be  photographed,  the  sheet  of 
lead  is  moved  so  as  to  cover  the  right  half  of  the  -plate  and  the  tube  is 
placed  immediately  over  the  left  edge  of  the  superior  outlet  of  the  pelvis, 
3  cm.  to  the  left  of  the  median  line.  Its  proper  position  being  obtained 
by  means  of  the  plumb  line,  the  photographic  plate  is  not  disturbed. 
An  exposure  is  then  made  of  this  part,  and,  thus,  a  photograph  of  the  two 
sides  of  the  brim  of  the  pelvis  is  obtained.  By  this  method  the  error 
due  to  the  slanting  direction  of  the  rays  falling  on  the  pelvic  brim  and 
the  plate  when  only  one  exposure  is  made  for  both  sides  is  avoided, 
and  no  calculation  is  necessary  to  estimate  the  amount  of  exaggeration, 
as  in  the  latter  case."  This  method  is  applicable  to  non-pregnant 
cases.  With  the  gravid  uterus  the  plate  cannot  be  brought  in  contact 
with  the  part. 

A  skiagraph  of  the  foetus  may  be  produced  quite  readily  after  it  has 
been  taken  from  the  uterus.  In  1896  Dr.  Oliver  diagnosed  one  ectopic 
gestation,  six  weeks  beyond  term,  in  a  woman  aged  39  years.  An  attempt 
was  made  to  radiograph  the  mass  within  the  abdominal  cavity,  but  the 
result  was  altogether  unsuccessful.  Operation  proved  the  presence  of 
an  ovarian  sac,  which  contained  a  nine-months'  foetus.  After  its  removal 
by  operation  a  successful  skiagram  of  the  foetus  was  produced.  Human 
foetuses  in  various  stages  of  development  are  to-day  quite  readily  and 
successfully  skiagraphed.  The  older  the  fcetus  the  better  will  be  the 
resulting  skiagraph. 

1 "  The  Rontgen  Rays  in  Medicine  and  Surgery,"  p.  379. 


366 


ELECTRO-THEK  A  I ' K I'TICS. 


Gravid  Uterus. — I  have  been  able  to  produce,  in  a  few  cases,  skia- 
grams of  gravid  uteri.  Dr.  E.  P.  Davis1  states,  that  his  experiments 
showed  that  it  is  possible  to  obtain  an  outline  of  the  living  fostus  in  the 
body  of  the  mother,  notwithstanding  the  thickness  of  the  tissues,  and  the 
distance  at  which  the  Crookes  tube  is  necessarily  placed  from  the  foetus. 
I  made  several  stereo-skiagrams  of  pregnant  women  at  the  Philadel- 
phia Hospital  for  Dr.  Davis,  and  the  result  was  eminently  successful. 

Anatomical  specimens  of  uteri,  and  their  contents,  removed  from  the 
body  should  occasion  no  difficulty.  By  varying  the  current  and  the  time 
of  exposure,  it  is  undoubtedly  possible  to  obtain  a  useful  picture  of  the 
contents  of  the  living  womb. 

Drs.  Henri  Yaruier  and  Ed.  Piuard  have  diligently  studied  the 
gravid  uterus,  both  in  the  living  and  the  dead,  by  means  of  the  Eontgeu 
rays.  In  the  case  of  a  woman  dying  from  uraemia,  they  were  enabled  to 


FIG.  197.— Author's  head  rest  for  stereoscopic  work. 

show  the  head  of  a  seven-months'  foetus  at  the  superior  strait.  In  the 
second  case,  after  death  from  some  form  of  lung  disease,  they  were  enabled 
to  show  the  contour  of  the  uterus,  together  with  a  part  of  the  vertebral 
column  of  the  contained  foetus. 

Queirel  and  Acquavita2  assert  that  the  evolution  of  the  osseous  sys- 
tem is  demonstrable,  at  premature  birth,  by  the  skiagraph,  and  hence 
the  determination  of  the  age  of  the  developing  foetus  assumes  an  impor- 
tance in  matters  of  medico-legal  interest. 

1  American  Journal  of  the  Medical  Sciences,  March,  1896,  p.  268. 
1  Bouchard,  "Traite  Radiologie  M&licale,"  p.  1009. 


APPLICATION  IN  THE  SPECIALTIES.  367 

GYNAECOLOGY. 

So  far  the  X-rays  Lave  been  of  little  practical  value  in  gynaecol- 
ogy. Before  long,  however,  correct  diagnoses  of  various  tumors,  cysts, 
abnormal  positions  of  the  uterus,  diseases  of  tubes  and  ovaries,  etc.,  will 
undoubtedly  be  made  by  means  of  the  Eontgen  rays.  At  present  the 
shadows  produced  upon  sensitive  plates  of  the  various  conditions  of  the 
pelvic  and  abdominal  organs  (except  the  bladder  and  prostate)  are 
insufficient  in  detail.  Dr.  Eden  V.  Delphey  l  says,  that  the  main  use  of 
the  X-rays  in  gynaecology  lies  in  the  treatment  of  malignant  disease,  and 
when  a  diagnosis  is  made  sufficiently  early,  the  neoplasm  and  often  all 
the  pelvic  reproductive  organs  should  be  removed  by  surgical  means,  so 
as  to  get  entirely  beyond  the  malignant  growth  and  prevent  recurrence. 
When  this  can  be  done,  the  protuberant  portion  should  be  removed  and 
the  remainder  subjected  to  the  influence  of  the  Eontgen  rays. 

II.    Rhinology,  Laryngology,  and  Otology. 

The  X-rays  are  at  present  coming  into  use  in  affections  of  the  nose, 
throat,  and  ear. 

EHINOLOGY. 

A  screen  examination  of  the  nasal  bones,  when  displaced,  depressed, 
or  fractured,  is  well  illustrated  by  this  means.  If  supports,  as  silver  or 
aluminium  splints,  are  placed  under  the  depressed  bones,  their  correct 
position  may  easily  be  ascertained  by  a  screen  examination  ;  the  same 
holds  good  for  exostoses  and  foreign  bodies.  Abscesses  of  the  antrum 
and  frontal  sinuses  may  be  readily  skiagraphed,  and  I  find  for  these  cases 
head  rests  (Figs.  197  and  198)  most  valuable. 

Diseases  of  the  frontal  sinuses  may  be  skiagraphed  in  the  occipito- 
frontal  and  lateral  positions.  The  former  is  difficult,  because  of  the 
thickness  of  the  skull.  By  this  view  we  note  on  the  plate  the  presence 
or  absence  of  these  sinuses,  also  their  size,  shape,  symmetry  or  asymmetry, 
the  number  of  septa,  the  presence  of  contained  morbid  products,  and  the 
extent  of  the  orbital  and  ethmoidal  recesses.  The  skiagraph  in  the  lateral 
position  is  easier  of  accomplishment,  but  it  fails  to  show  the  details  above 
mentioned,  because  only  one  side  is  taken  and  therefore  forbids  compari- 
son ;  but  it  shows  clearly  the  ethmoidal  and  orbital  recesses  and  the 
sphenoidal  sinuses.  Both  views  should  always  be  skiagraphed.  The  den- 
tiaskiascope,  or  endodioscope,  first  described  by  Dr.  Macintyre  and  used 
for  examining  the  hard  and  soft  tissues  about  the  bones  of  the  face,  nose, 
and  larynx,  deserves  mention.  Dr.  Macintyre  writes  as  follows  :2  "The 
fluorescent  screen  is  placed  inside  of  the  mouth  and  the  Crookes  tube  out- 
side, or  vice  rci-wi.  Small  disks  of  glass  are  coated  with  the  fluorescent 


1  Annals  of  Gynaecology  and  Pediatrics,  Feb.,  1903. 

2  Glasgow  Hospital  Reports,  1898,  p.  306. 


368 


ELECTRO-THERAPEUTICS. 


salt  and  covered  with  aluminium,  or  tongue  depressors  consisting  of  flat 
strips  of  glass  covered  and  coated  in  the  same  way  may  be  employed.  By 
placing  the  tube  outside,  I  am  able  to  get  an  image  of  the  septum  and 
other  parts  of  the  cavity  of  the  nose,  on  the  fluorescent  screen  in  the 
mouth.  In  the  same  way  the  roots  of  the  teeth  may  be  seen.  If  the 
surgeon  desires  to  examine  the  tissues  externally, — i.  ?.,  to  pass  the 


FIG.  198.— AUTHOR'S  HEAD  REST  FOB  SKIAGRAPHING  DISEASES  OF  THE  FRONTAL  SINUSES.— With 
this  device,  the  patient  is  seated  and  his  head  or  face  is  applied  to  the  board.  There  are  two  movable 
padded  head  rests,  one  on  the  vertex  and  the  other  under  the  occiput;  the  chin  is  supported  on  a  rest. 
P.  H.  is  a  plate-holder  lined  with  a  transi>arent  material,  into  which  the  sensitive  plate  can  be  slid  or 
inserted.  It  is  also  very  convenient  for  stereoscopic  work.  This  plate-holder  can  be  adjusted  according 
to  the  angle  of  the  face  and  forehead,  as  shown  in  the  scale,  and  fastened  at  any  angle.  I  find  that  a 
30-degree  angle  is  the  best  position  for  the  patient.  This  angle  is  formed  by  the  glabella  G,  the  exter- 
nal auditory  meatus,  and  the  anode  of  the  Crookes  tube.  As  the  facial  angle  varies  in  different  individ- 
uals, it  is  necessary  to  adjust  the  tube  accordingly.  The  more  obtuse  the  facial  angle,  the  more  acute 
should  be  the  angle  between  the  bundles  of  rays  and  the  base  of  the  skull,  or  a  line  connecting  the 
external  auditory  meatus  and  the  glabella.  The  more  acute  the  facial  angle,  the  more  obtuse  shotCd 
be  the  angle  formed  by  the  tube.  The  X-rays  should  form  as  near  a  right  angle  to  the  plate  as  possible, 
always  avoiding  the  shadow  of  the  occipital  bone.  If  the  rays  are  directed  through  the  cervical  region, 
the  shadows  of  the  vertebrae  will  throw  irregular  shadows  over  the  sinuses.  I  find  that  this  is  un- 
satisfactory. 

rays  through  the  neck, — we  can  place  a  small  fluorescent  screen  on 
one  side  and  remove  the  Crookes  tube  to  a  suitable  distance.  By  this 
means  I  have  been  able  to  demonstrate  the  presence  of  foreign  bodies, 
and  need  hardly  add  that  they  are  more  easily  photographed." 

Monnier1  is  able  to  diagnose  the  etiological  factors  of  a  chronic 

1  Archives  Internal,  de  Laryngologie,  November  3, 1898. 


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5  2  £  5  =  =. 


APPLICATION  IX  THE  SPECIALTIES.  369 

post-nasal  suppuration  associated  with  epiphora.  He  gives  a^  the  cause  a 
piece  of  a  lacrymal  sound  which  had  remained  in  the  nasal  duct  for  some 
twenty  years. 

LARYNGOLOGY. 

While  the  X-rays  have  accomplished  but  little  in  the  department  of 
laryngology,  they  have  proved  of  great  service  in  the  detection  and 
accurate  localization  of  foreign  bodies  in  the  upper  portion  of  the  diges- 
tive and  respiratory  tracts,  thus  aiding  the  laryngologist  to  decide  as  to 
the  advisability  and  character  of  operations  for  their  removal ;  also  in 
the  determination  of  the  ossification  of  structures  in  the  laryngeal  and 
tracheal  cartilages.  At  present  we  can  ascertain  with  scientific  accuracy 
the  time  and  the  points  at  which  all  the  cartilages  ossify.  The  X-rays 
aid  in  the  diagnosis  of  intra-thoracic  growths  involving  the  respiratory 
tract,  either  by  compression  of  the  trachea,  or  by  some  form  of  vocal-cord 
paralysis.  They  are  also  likely  to  prove  useful  in  the  earliest  detection 
of  any  tuberculous  processes  in  the  lungs.  The  observer  must  be  trained 
to  this  line  of  observation  in  order  that  perfection  may  be  obtained.  The 
delicate  variations  in  the  shadows  that  form  on  the  fluorescent  screen  can 
be  properly  interpreted  only  by  practice.  Fig.  199  shows  the  presence  of 
a  tumor  in  the  trachea. 

OTOLOGY. 

The  rays  have  been  of  slight  value  in  otology.  In  two  cases  where 
foreign  bodies  had  been  introduced  into  the  ear,  I  was  able  to  detect  and 
localize  them  by  means  of  the  X-rays.  In  each  instance  the  external 
auditory  canal  was  greatly  inflamed  and  swollen,  so  as  to  prevent  an 
ordinary  examination  of  the  part  with  a  satisfactory  result. 

The  diagnosis  of  mastoid  abscess  by  the  X-rays  is  feasible.  Three 
cases  examined  by  me  showed  the  presence  of  abscesses,  and  subse- 
quent operations  confirmed  the  diagnoses.  In  all  these  cases  the  nega- 
tives showed  a  dense  shadow  instead  of  the  porous  appearance  found 
normally. 


CHAPTER  VII 
APPLICATION  IN  DENTISTRY. 

THE  employment  of  the  X-rays  iii  dentistry  has  opened  up  a  prom- 
ising field.1  Thus  far  skiagraphy  has  rendered  invaluable  aid,  assisting 
the  dental  surgeon  in  diagnosticating  perplexing  conditions  and  in  con- 
firming conclusions  previously  obtained.  Thus,  the  position'of  the  roots, 
the  occurrence  of  fracture  of  a  root,  the  presence  of  alveolar  absorption, 
the  existence  of  fluid  in  the  antruin,  and  many  other  pathological  states 
and  conditions  are  readily  revealed  to  us  through  this  method  of 
investigation.  The  structure  and  evolution  of  the  teeth  can  be  studied 
in  the  living  subject. 

I.  Apparatus  Used  in  Dental  Skiagraphy. 

The  paraphernalia  and  technic  employed  in  dental  skiagraphy  do 
not  differ  from  those  used  for  other  regions  of  the  body.  A  small  coil  of 
6-  or  7-inch  spark  length  is  sufficient.  For  the  denser  structures,  as,  for 
instance,  the  entire  thickness  of  the  maxillary  bones,  a  tube  of  high 
vacuum  is  essential ;  the  same  kind  of  tube  should  be  employed  where 
the  skiagram  must  be  taken  rapidly,  and  where  the  exposure  is  con- 
sequently short,  as  in  cases  of  children. 

II.  Technic. 

Fluoroscopic  examinations  in  dentistry  do  not  yield  satisfactory 
results.  The  two  methods  at  present  employed  in  dental  skiagraphy  are 
the  intra-oral  and  the  extra-oral  or  buccal. 

The  intra-oral  method  consists  in  inserting  a  small  piece  of  film  (light 
and  moisture  proof)  over  the  alveolar  tissue  where  trouble  is  suspected, 
and  in  adjusting  the  tube  so  that  perpendicular  rays  will  fall  upon  the 
teeth  and  film.  A  small  sensitive  plate,  being  inflexible,  cannot  be  made 
to  adapt  itself  to  the  curvature  of  the  part.  Rollins,  of  Boston,  encases 
the  film  in  an  aluminium  cover,  while  Price,  of  Cleveland,  Ohio,  uses 
un vulcanized  black  dental  rubber,  protecting  the  emulsion  with  a  sheet 
of  sensitive  bromide  paper.  Kodak  films  cannot  be  used  for  this 

1  The  first  skiagraph  of  the  teeth  was  exhibited  by  Prof.  Koenig,  to  the  Society 
of  Physics  of  Frankfort-on-the-Main,  in  February,  1896. 

In  April,  1896,  at  the  Congress  of  Erlangen,  Walkoff  demonstrate  1  many  skia- 
graphs of  the  teeth  in  living  subjects.  (Bouchard,  "TraiU-  Radiologu-  .M<  cli.  ale.") 

Dr.  William  J.    Morton  on    "The  X-rays   in  Dentistry."  which  appeared   in 
Dental  Cosmo*,  June,  1896,  reproduced  from  his  book  :    "  The  X-rays,  or  Photography 
of  the  Invisible." 
370 


APPLICATION  IN  DENTISTKY.  371 

purpose.  Formerly  I  preferred  a  specially  prepared,  thick,  double- 
coated  film,  which  I  cut  to  the  required  size  and  enclosed  in  a  layer  of 
black  paper,  after  which  the  paper  was  so  folded  as  to  enclose  snugly 
the  film,  and  the  wrhole  placed  in  a  yellow  envelope  just  large  enough  to 
accommodate  the  size  of  the  paper  and  film  ;  the  smooth  side  correspond- 
ing to  the  sensitive  side  of  the  film.  Lately  I  have  much  preferred 
Eastman's  negative  transparent  films,  which  are  neatly  encased  and 
always  ready  for  use. 

Place  the  patient  in  the  dental  chair  and  adjust  the  tube.  See  that 
the  rays  fall  perpendicularly  to  the  vertical  axis  of  the  teeth.  If  the 
adjustment  of  the  tube  is  faulty,  the  shadows  of  the  teeth  will  be 
distorted.  In  order  to  include,  in  the  skiagraph,  the  roots  of  the  teeth 
place  the  film  against  the  hard  palate.  Before  its  introduction  into  the 
mouth,  the  enveloped  film  should  be  reinforced  by  a  couple  of  rubber 
bands.  Skiagraphic  work  on  the  superior  maxillary  bone  is  less  satis- 
factory than  upon  the  inferior  maxillary,  as  the  film  cannot  be  brought 
in  a  line  parallel  with  the  teeth.  Two  films  can  be  exposed  at  one 
time.  As  only  one  or  two  teeth  can  be  included,  the  film  should  be 
pressed  against  the  affected  part,  the  exposure  varying  from  two  to  ten 
seconds.  By  this  method  sharper  definition  on  the  negative  is  obtained, 
and  only  a  small  area  is  skiagraphed. 

The  extra-oral  or  buccal  method  (Fig.  200)  requires  a  plate  8  x  10  to  be 
brought  in  contact  with  the  jaw  at  the  suspected  region.  A  block  of  wood 
is  wedged  between  the  widely  extended  jaws,  and  the  patient  is  directed 
to  lie  upon  the  affected  side,  and  to  incline  the  head  and  neck  to  an  angle 
of  about  45  degrees.  The  tube  is  now  placed  on  the  opposite  shoulder,  the 
latter  is  protected  by  a  sheet  of  lead  (the  tube  being  placed  very  close  to 
the  shoulder),  and  the  rays  are  sent  obliquely  at  a  distance  of  20  to  25 
inches  (50-63  cm.)  from  the  face,  to  avoid  overlapping  of  the  shadows 
of  the  jaw.  This  method  produces  a  picture  of  great  area,  and  is 
intended  for  bicuspids  and  molars  of  both  jaws.  Exposure  varies  from 
half  a  minute  to  two  minutes. 

Dr.  Sinclair  Tousey,1  of  New  York  City,  thus  describes,  "A  new 
film-carrier  and  indicator  for  dental  radiography  with  projection  upon  a 
horizontal  plane." 

"It  consists  of  a  stiff  card  two  and  one-half  inches  (6  cm.)  wide  and 
five  inches  (13  cm.)  long,  covered  at  one  end  by  a  sheet  of  rubber  dam, 
which  forms  a  pocket  into  which  the  film,  wrapped  in  black  paper,  may 
be  slipped.  This  end  is  placed  horizontally  in  the  patient's  mouth,  and 
held  there,  by  tightly  closing  the  lips  and  teeth.  The  part  of  the  card 
which  projects  from  the  patient's  mouth  has  a  clamp  of  aluminium, 
which  may  be  turned  to  either  side  or  straight,  and  carries  a  thin 
aluminium  rod  which  is  always  held  at  the  proper  angle  to  the  plane  of 

1  Archives  of  Physiological  Therapy,  September,  1905. 


372  ELECTRO-THERAPEUTICS. 

the  film.  Diagrams  of  the  teeth  are  printed  upon  both  the  upper  and 
lower  surface  of  the  card,  and  serve  to  indicate  the  position  to  which  the 
aluminium  pointer  must  be  turned  laterally. 

"  For  radiographing  the  upper  jaw  the  patient  sits  erect  with  a  film- 
carrier  in  his  mouth.  The  pointer  is  turned  to  the  position  on  the  dia- 
gram where  the  teeth  of  chief  interest  are  located,  and  the  X-ray  tube  in 
a  Friedlander  shield  is  brought  into  a  position  to  correspond  with  the 
position  of  the  pointer.  In  other  words,  we  have  an  aluminium  rod 
which  points  to  the  spot  where  the  auticathode  of  the  tube  should  be 
placed.  For  the  lower  jaw,  a  film-carrier  is  turned  down,  and  it  will 
often  be  found  desirable  to  tilt  the  patient's  head  somewhat,  in  order  to 
cause  the  indicator  to  point  to  a  spot  at  which  it  is  practicable  to  place 
the  X-ray  tube.  It  is  hardly  necessary  to  add  that,  since  the  incisor 
teeth  are  an  inch  behind  the  pivot  of  the  indicator,  the  auticathode  must 
be  placed  in  corresponding  relation  to  the  pointer. 

"The  value  of  the  film-carrier  and  indicator  lies  in  the  fact  that  it 
readily  and  securely  holds  the  film  in  position,  without  placing  the 
finger  inside  the  patient's  mouth.  The  proper  relation  of  tube  and  film 
are  very  readily  acquired.  The  picture  obtained  gives  an  exact  measure 
of  the  length  of  the  teeth,  and,  most  important  of  all,  the  teeth  of  the 
whole  side  or  front  of  the  jaw  may  be  shown  on  one  film.  By  using  an 
unusually  wide  film,  it  is  practicable  to  secure  a  picture  of  very  good 
definition,  of  the  teeth  of  both  sides  of  the  lower  jaw,  and  also  of  the 
incisor  teeth,  but  the  latter,  of  course,  would  be  a  confused  overlap 
ping  mass.  The  radiograph  of  the  upper  jaw  may  show  all  the  front 
teeth,  or,  if  taken  at  the  side,  all  the  side  teeth  and  the  antrum  of 
Highmore.  To  get  the  wisdom-teeth,  either  upper  or  lower,  the  baek  of 
the  film  must  be  held  far  back  in  the  mouth,  but  this  is  less  unpleasant  to 
the  patient  than  the  more  usual  way  of  pressing  a  small  film  against  the 
inside  of  the  jaw  far  enough  back  for  that  purpose.  The  greater  ease 
with  which  it  is  practicable  to  show  the  entire  vertical  width  of  the  lower 
jaw  is  an  additional  advantage." 

III.  Clinical  Applications. 

Unerupted  Teeth. — An  important  condition  coming  under  the  dentist's 
care  is  the  retention  or  non-eruption  of  a  permanent  tooth,  owing  to  the 
temporary  tooth  remaining  in  the  alveolar  socket,  beyond  the  age  con 
sidered  normal.  If  the  skiagram  reveals  the  unerupted  tooth  to  be  of 
normal  shape  and  so  located  as  to  permit  of  its  eruption,  the  indication 
is  to  remove  the  temporary  tooth.  Many  cases  of  odoutalgia  are  un- 
doubtedly due  to  an  unerupted  tooth  ;  in  such  cases  the  etiological  factor 
may  be  revealed  by  the  X-rays.  (Figs.  201,  202,  203,  204,  2or>,  206.) 

Necrosis  of  the  Maxilla. — Necrosis  of  the  superior  or  inferior  maxillary 
bone  can  readily  be  shown  by  careful  X-ray  examinations.  (Fig.  207.) 


FIG.  200. — EXTRA-ORAL  METHOD  IN  DENTAL  SKIAGRAPHY. — LS,  lead  screen  for  the  protection  of 
the  operator.  The  arrows  indicate  the  variable  positions  to  which  the  author's  tube-holder  may  be 
shifted.  The  illustration  depicts  the  sensitive  plate  placed  upon  a  book  and  the  lad's  left  (suspected 
side)  cheek  resting  on  the  plate,  the  dotted  line  shows  the  path  of  the  rays. 


Fio.  201.— UNERUPTED  TEETH.— Malposition  of  the  wisdom  tooth  in  the  lower  ri*ht  jaw  and  delayed 
eruption  of  the  wisdom  tooth  in  the  rijfht  upper  jaw,  the  latter  indicated  by  dotted  lines. 


PIG.  20-  — r.NKRriTEn  T'PI-ER  CrsiMD  TOOTH.— The  patient  presented  a  swelling  nt  the  ala  of  the  nose 
with  reflex  nasal  and  crbital  symptoms.    (Case  of  M.  H.  Cryer.) 


FIG.  203. — DELAYED  ERUPTION  OF  THE  UPPER  CC?PID  TOOTH — The  bridge  is  separating  the  first  from 

the  lateral  teeth  on  each  side. 


Fie.  204.— DELAYED  ERUPTION  OR  THE  UPPER  CTSPID  TOOTH.— The  temporary  teeth  are  in  situ. 
of  the  latter  was  removed,  when  the  permanent  cuspid  tooth  was  detected. 


One 


FIGS.  205,  206.— Delayed  second  bicuspid  on  both  sides  of  the  lower  jaw,  in  a  girl  of  12.  The  upper 
picture  is  the  right  side  of  lower  jaw,  and  the  lower  the  left  side  oi  lower  jaw.  (Case  of  Drs.  Cryer  and 
Smith.) 


FIG.  207.— PHOSPHOROUS  NECROSIS  OF  THE  INFERIOR  MAXILLA.— Dotted  area  shows  the  portion  of  bone 

removed.    (Case  of  Dr.  Cryer. ) 


FIG.  208.— CHRONIC  ALVEOLAR  ABSCESS  or  THE  RIGHT  CENTRAL  INCISOR  TOOTH.— Patient,  age  18, 
treated  for  the  above  condition  for  a  period  of  four  years,  having  six  sinuses  on  the  labial  surface  of 
the  gum.  X-rays  reveuled  remnants  of  foreign  body  at  the  apex  of  the  root.  Dr.  C.  F.  Horgan  removed 
the  tooth  (right  central  incisor),  and,  after  cleaning  and  filling,  the  tooth  was  reimplanted.  Two  years 
later  the  patient  remained  absolutely  well,  and  the  tooth  is  giving  good  service. 


APPLICATION  IX  DENTISTRY.  373 

A  necrotic  condition  of  the  jaw,  especially  when  advanced,  as  in  phos- 
phorus poisoning,  gives  the  skiagram  a  lighter  area  than  is  produced  by 
the  adjacent  unaffected  bone.  In  a  few  cases  that  have  coiue  to  iny  notice, 
I  have  observed  a  peculiar  condition, — namely,  an  irregular  arrangement 
of  the  teeth,  failing  to  remain  in  the  sockets,  as  seen  normally.  The  light 
area  produced  by  necrosis  is  undoubtedly  due  to  a  decrease  of  organic 
material,  replaced  partially  by  an  increased  amount  of  inorganic  salts. 
In  a  case,  referred  to  me  by  Dr.  Cryer,  the  patient  presented  a  swell- 
ing at  the  angle  of  the  lower  jaw.  A  skiagraph  showed  the  absence 
of  true  osseous  tissue.  The  part  was  curetted,  and,  three  months  later,  at 
a  clinic  at  the  Philadelphia  Hospital,  the  skiagram  revealed  a  regenera- 
tion of  the  osseous  tissue. 

Ankylosis  of  the  Inferior  Maxillary  Articulation. — This  may  be  true  or 
false,  partial  or  complete,  depending  upon  the  cause.  Fluoroscopic 
examinations  in  this  condition  are  unsatisfactory,  except  for  observing 
the  movements  of  the  temporo- maxillary  articulation.  The  skiagram  is 
taken  by  the  extra-oral  method.  A  negative  showing  the  affected  joint 
in  the  early  stages  usually  presents  an  irregularity  of  the  articulating 
cartilaginous  surfaces.  In  true  ankylosis,  as  when  following  a  fracture 
involving  a  joint,  the  latter  may  be  seen  to  be  wholly  obliterated.  In 
false  aukylosis,  the  joint  is  seen  to  be  much  eroded,  the  fibrous  adhesions 
not  being  evident  unless  they  have  become  partially  infiltrated  with 
inorganic  salts. 

Fracture  of  the  Inferior  Maxillary  Bone. — For  this  injury  employ  the 
methods  before  described.  In  fracture  of  the  symphysis,  the  plate  should 
be  placed  under  the  chin,  the  inferior  maxilla  being  fully  extended,  in 
order  that  the  rays  may  penetrate  the  injured  part  from  above.  Some 
prefer  to  place  within  the  oral  cavity  a  film,  and  have  the  rays  pass 
from  the  outside,  as  employed  for  unerupted  teeth.  The  progress  of  repair 
in  this  fracture,  as  well  as  in  others  involving  this  bone,  may  be  easily 
determined  by  frequent  fluoroscopic  examinations. 

Broken  Instruments. — Xot  infrequently  a  dentist,  in  his  endeavor  to 
fill  the  root  canal,  breaks  an  instrument,  the  fragment  remaining  inside 
the  cavity.  In  his  endeavor  to  remove  the  particle,  he  may  cause  it  to 
become  lodged  more  tightly  and  further  up  in  the  cavity.  An  X-ray 
examination  will  enable  him  to  decide  upon  a  course  most  suitable  for  its 
early  removal. 

Root-Canal  Fillings. — An  X-ray  examination  will  demonstrate  whether 
a  canal  has  been  properly  filled  or  not.  Such  an  examination  after  the 
filling  of  a  root-canal  would  accomplish  much  toward  the  prevention  of 
an  alveolar  abscess. 

Abscess  of  the  Antrum. — Pus  or  other  fluid  in  the  antruin  of  Highmore 
may  readily  be  seen  by  careful  fluoroscopic  examinations.  The  X-rays 
are  eminently  practicable  in  diagnosticating  various  diseases  of  the 
antrum.  Foreign  bodies,  as  roots  of  teeth,  are  located  with  exactness, 


374  ELECTRO-THERAPEUTICS. 

and  the  relations  of  the  teeth  to  the  ant  rum  or  abscesses  about  them  may 
clearly  be  demonstrated,  also  the  position  and  shape  of  the  floor  of  the 
antruni,  the  presence  of  fluid  or  pus,  etc.,  which  may  be  contained 
therein. 

Alveolar  Abscess. — Dead  pulp  in  a  tooth  indicates  a  break  in  the  con- 
tinuity of  the  pericemental  membrane  at  the  apex  of  the  root,  and  more 
or  less  absorption  of  the  adjacent  osseous  tissue,  and  occasionally  of  the 
roots  in  long-standing  cases.  In  the  majority  of  instances  such  an  al»«  >- 
is  due  to  imperfect  treatment,  but  in  many  cases  the  canal  of  the  root  is 
so  narrow  and  irregular  as  to  make  it  almost  impossible  to  fill  the  canal 
or  cavity  to  the  apex.  When  a  case  presents  symptoms  of  a  pericemental 
inflammation  and  the  history  is  uncertain,  the  most  rational  procedure 
is  first  to  skiagraph  the  field,  thus  ascertaining  the  exact  location  and 
extent  of  the  lesion  and  often  its  cause.  (Fig.  208. ) 

Tumors,  such,  as  sarcomata  or  carciuomata,  that  frequently  develop 
in  the  antrum,  can  in  some  cases  be  demonstrated  by  careful  X-ray  exam 
inations.     A  cavity  that  is  free  from  pus,  blood,  other  fluid,  or  tumors 
shows  a  clearer  and  more  sharply  defined  shadow  than  where  one  of  the 
conditions  just  named  is  present. 

Orthodontia. — In  deformities  of  the  jaws  due  to  or  associated  with 
unerupted  teeth,  the  dental  skiagrapher  can  ascertain  with  great  exact- 
ness the  size,  shape,  and  position  of  the  teeth  within  the  bones. 

Occasionally  the  dentist  is  called  upon  to  regulate  teeth,  and  before 
so  doing  it  is  advisable  for  him  to  know  the  exact  position  of  the  roots, 
and  also  to  what  extent  the  tooth  canals  are  closed.  If  the  apex  of  the 
root  is  not  fully  developed,  the  teeth  can  be  regulated  more  rapidly 
and  without  danger  of  destroying  the  pulp. 


CHAPTER    VIII 
THE  ROXTGEX  KAYS  IX  FOREXSIC  MEDICINE. 

I.  The  Legal  Status  of  the   X-Ray. 
A.  ADMISSIBILITY  IN  VARIOUS  STATES. 

EVER  since  Prof.  Rontgeu's  immortal  discovery  has  been  applied  as 
a  diagnostic  agent  in  medicine  and  surgery,  the  legal  status  of  the  X-ray 
has  been  argued,  denounced,  and  defended  by  attorneys  the  world  over. 
It  seems  most  fitting  to  quote  a  few  lines  from  the  comprehensive  contri- 
bution of  the  Hon.  W.  W.  Goodrich,  Presiding  Justice,  Appellate  Divi- 
sion of  the  Supreme  Court  of  the  State  of  New  York,1  second  judicial 
department. 

"  The  general  rule  with  regard  to  ordinary  photographs  has  long  been 
that,  wherever  the  person  or  thing  would  under  general  rules  be  relevant 
if  produced  in  court,  or  the  jury  would  be  permitted  to  see  it  if  conven- 
ient, a  photograph  of  such  person  or  thing,  if  properly  authenticated,  is 
admissible  when  the  original  cannot  be  seen.  Whenever  the  jury  are 
likely  to  be  materially  aided  by  the  opinions,  on  matters  of  fact,  of  per- 
sons specially  qualified,  they  should  have  them,  and,  for  the  purpose  of 
illustrating  and  making  clear  the  testimony  of  medical  and  surgical 
experts,  photographs  taken  by  the  Rontgen  or  X-ray  process  have  been 
admitted  as  evidence  in  the  courts  of  several  of  the  states.  A  reference 
to  these  cases  will  show  the  present  status  of  the  law  upon  the  subject. 
The  first  case  in  which  the  question  arose  in  this  country  is  unreported, 
but  there  is  a  summary  of  it  in  the  Chicago  Legal  News.  It  was  decided 
in  Colorado,  in  1896,  and,  in  admitting  the  X-ray  photograph,  the  learned 
Judge  Lefevre  said :  '  During  the  last  decade  at  least,  no  science  has 
made  such  mighty  strides  forward  as  surgery.  It  is  eminently  a  scien- 
tific profession,  alike  interesting  to  the  learned  and  unlearned.  It  makes 
use  of  all  science  and  learning.  It  has  been  of  inestimable  value  to  man- 
kind. It  must  not  be  said  of  the  law  that  it  is  wedded  to  precedent ; 
that  it  will  not  lend  a  helping  hand.  Rather,  let  the  courts  throw  open 
the  door  to  all  well-considered  scientific  discoveries.  Modern  science  has 
made  it  possible  to  look  beneath  the  tissues  of  the  human  body,  and  has 
aided  surgery  in  telling  of  the  hidden  mysteries.  We  believe  it  to  be  our 
duty  in  this  case  to  be  the  first,  if  you  please  to  so  consider  it,  in  admit- 
ting in  evidence  a  process  known  and  acknowledged  as  a  determinate 
science.' ' 

Probably  the  leading  case  in  this  country  on  the  subject  under  dis- 
cussion is  that  of  Bruce  vs.  Beall  (99  Tenn.  303),  decided  September  30r 

1  Brooklyn  Medical  Journal,  December,  1903. 

375 


876  ELBCTBQ-THEBAPEUTIOS. 

IMC.  Judge  Beard,  writing  for  the  Court,  said:  "In  the  progress  of 
the  trial,  one  Dr.  Gait  man  was  introduced  as  a  witness,  and  he  was  per- 
mitted to  submit  to  the  jury  an  X-ray  photograph,  taken  by  him,  show- 
ing the  overlapping  bones  of  one  of  the  plaintiffs  legs,  at  a  point  where 
it  was  broken  by  this  fall.  This  was  objected  to  by  the  defendant's 
counsel.  This  picture  was  taken  by  the  witness,  who  was  a  physician  and 
surgeon,  not  only  familiar  with  fractures,  but  with  the  new  and  interesting 
process  by  which  this  particular  impression  was  secured.  He  testified, 
that  this  photograph  accurately  represented  the  condition  of  the  leg  at 
the  point  of  the  fracture  in  question,  and,  as  a  fact,  that  by  the  aid  of 
X  rays  he  was  enabled  to  see  the  broken  and  overlapping  bones  with  his 
own  eyes,  exactly  as  if,  stripped  of  the  skin  and  tissues,  they  were 
uncovered  to  the  sight.  We  might,  if  we  so  desired,  rest  our  conclusion 
on  the  general  character  of  the  exception  taken  to  this  testimony,  but  we 
prefer  to  place  it  on  the  ground  that,  verified  as  was  this  picture,  it 
\\as  altogether  competent  for  the  purpose  for  which  it  was  offered.  New 
as  this  process  is,  experiments  made  by  scientific  men,  as  shown  by  this 
record,  have  demonstrated  its  power  to  reveal  to  the  natural  eye  the 
entire  structure  of  the  human  body,  and  that  its  various  parts  can  be 
photographed,  as  its  exterior  surface  has  been,  and  now  is." 

It  is  the  opinion  of  some  of  the  judges  of  Massachusetts,  that  X-ray 
photographs  are  not  admissible  as  evidence,  contending  that  as  cold 
scientific  truths  they  cannot  be  regarded  as  accurate.  No  one  can  posi- 
tively attest  to  the  absolute  correctness  of  the  reproduction.  The  truth- 
fulness of  the  photograph  is  a  matter  of  reasoning.  In  the  Philadelphia 
courts,  the  skiagram  is  admitted  as  corroborative  evidence,  provided  that 
it  has  been  executed  by  an  expert  in  the  work  ;  the  same  ruling  is  in  force 
in  the  English  courts.  In  Nebraska,  the  courts  of  final  jurisdiction  main- 
tain that  skiagrams  must  be  taken  by  competent  persons,  who  must  be 
able  authoritatively  and  indisputably  to  assert,  that  the  appearances 
shown  are  accurate  representations  of  the  part. 

In  a  malpractice  suit,  Carlson  vs.  Benton,  in  a  Nebraska  court,  it  was 
decided  by  the  judge  that  a  skiagram  could  be  introduced  as  evidence, 
despite  the  fact  that  the  skiagrapher  was  not  experienced  in  this  special 
field  of  work. 

In  this  case,  an  X-ray  photograph  of  an  injured  leg,  taken  after  the 
injury  had  been  treated  by  the  defendant,  was  offered  in  evidence.  The 
uncontradicted  testimony  of  three  surgeons  left  no  room,  for  a  difference 
of  opinion  as  to  the  accuracy  of  the  photograph,  the  court  maintaining 
that  to  exclude,  under  such  circumstances,  the  skiagram  as  evidence,  on 
the  ground  that  a  sufficient  foundation  had  not  been  laid,  was  an  abuse 
of  discretion. 

In  medico-legal  cases  the  X-rays  are  of  inestimable  value  to  the  phv- 
sieian  or  surgeon  in  sustaining  a  diagnosis,  to  the  patient  who  is  insti- 
tuting the  suit,  and.  laMlv,  and  probably  most  important,  to  the  judge 


THE  KOXTGEX  KAYS  IX  FOKEXSIC  MEDK'IXE.          377 

and  jury,  to  whom  medical  terms  and  expressions  are  often  so  wholly 
unintelligible.  A  skiagram  of  good  ''definition"  can  be  fairly  well 
interpreted  by  the  average  layman,  and  it  will  often  assist  an  attorney  in 
determining  whether  a  case  should  be  compromised  or  carried  to  court. 

The  courts  are  always  disposed  to  permit  an  exposition  of  scientific 
methods  that  will  elucidate  the  intricate  questions  submitted  for  judg- 
ment. In  certain  tribunals,  where  the  skiagram  is  rigorously  excluded, 
fluoroscopic  examinations  in  the  presence  of  the  judge  and  jury  are 
permitted,  and  the  knowledge  gained  therefrom  is  counted  as  evidence. 

The  physician  or  surgeon  (and  this  applies  especially  to  the 
beginner)  should  always  be  guarded  in  expressing  a  positive  opinion,  as 
to  the  results  that  may  be  expected,  after  a  difficult  fracture,  such  as  one 
involving  the  elbow,  or  the  likelihood  of  the  absence  of  deformity  in  a 
fractured  clavicle,  or  the  prevention  of  limping  after  fracture  of  the 
femur,  etc.  In  any  case  where  serious  deformity  and  inconvenience  may 
or  may  not  result,  that  physician  is  wisest  who  ventures  only  the  truth, 
explaining  the  probable  results  and  informing  the  sufferer  and  his 
friends  that  he  will  do  the  very  best  he  can  under  the  circumstances. 
In  those  cases  where  one  is  quite  sure  of  a  correct  diagnosis,  and  the  plan 
of  treatment  is  the  one  customarily  followed,  a  prognosis  may  be  given 
with  a  reasonable  degree  of  certainty.  All  prognoses  may  be  rendered 
slightly  more  favorable  when  the  general  condition  of  the  patient  is 
good  and  there  is  an  absence  of  any  complicating  conditions. 

In  certain  cases,  the  lines  of  treatment  pursued  may  be  perfectly 
proper,  but  if  the  patient  is  subject  to  the  misfortune  of  having  other 
maladies,  as  epileptic  seizures,  he  may,  by  falling,  cause  a  displacement 
of  a  properly  reduced  fracture,  in  which  case  the  attending  physician  or 
surgeon  is,  of  course,  not  held  responsible. 

B.  TECHNIC  OF  MEDICO-LEGAL  SKIAGRAPHY. 

The  techuic  in  these  cases  demands  special  care,  so  that  the  negative 
shall  be  sharp  and  clear.  It  is  not  only  advisable,  but  admissible  in 
many  of  the  courts,  to  have  a  detailed  history  of  the  case  jotted  down, 
the  health  of  the  patient  prior  to  the  injury,  the  time  and  the  manner 
in  which  the  accident  occurred,  and  the  method  of  treatment  pursued ; 
;iv  well  as  the  character  and  location  of  any  marks  on  the  patient's 
body,  the  length  of  time  that  they  remained,  etc. 

The  condition  of  the  heart,  lungs,  and  other  organs  after  the 
accident  must  not  be  overlooked.  First,  the  patient  should  be  most  care- 
fully examined  in  a  darkened  room  by  means  of  a  screen  or  fluoroscope, 
in  such  a  manner  that  he  and  his  attendants  may  not  observe  the  result 
obtained  by  the  examination.  The  examiner  should  never  be  alone  when 
examining  the  patient,  but  should  preferably  have  a  physician  or  surgeon, 
or  another  X-ray  expert,  to  verify  the  facts  observed.  The  information 


378  ESLBCTBO-THERAPBUTICS. 

\\i\\>  ^ained  should  remain  secret.  Following  the  rluoroscopic  exami- 
nation. a  skiagram  should  be  taken  and  developed  later,  so  that  a  record 
of  the  injury  may  be  preserved.  Two  plates  should  be  placed  one  on  top 
of  another,  so  that  two  negatives  may  be  had  for  future  reference. 
Occasionally  a  plate  is  spoiled  during  developing,  and  the  patient  refuses 
to  undergo  a  second  examination  ;  still  the  examiner  has  in  his  possession 
a  good  record  of  the  case.  The  plate  should  always  be  placed  in  position 
in  the  presence  of  a  witness,  and  it  should  have  a  mark  upon  it.  such  as 
a  key,  ring,  or  letters,  so  that  the  operator  may  be  able  to  identify  the 
part  or  side  from  which  the  negative  was  taken.  The  record  should  be 
kept  in  a  book,  together  with  the  history  of  the  case  and  a  detailed 
account  of  the  time  of  exposure,  the  distance  of  the  tube,  the  number  of 
amperes  and  voltage  of  current  used,  the  kind  of  apparatus  employed. 
etc.  Negatives  of  the  part  should  always  be  produced  from  directly 
opposite  points  of  view,  and,  where  possible,  the  injured  and  corre- 
sponding normal  parts  should  be  carefully  skiagraphed  for  purposes  of 
comparison.  After  developing  the  plate,  no  information  regarding  it 
should  be  imparted  except  to  counsel  or  the  attending  physician. 

The  negatives  should  be  prepared  prior  to  going  to  court.  To 
render  them  more  intelligible  to  the  judge  and  jury,  the  names  of  the 
bones  seen,  ete.,  should  be  written  on  them,  whether  right  or  left,  lateral, 
aitero-posterior,  etc.  An  arrow,  or  other  mark,  should  be  on  the 
negative,  to  elucidate  the  seat  of  fracture,  dislocation,  or  other  injury, 
and  also  the  date  of  its  taking.  Under  no  circumstances  should  any  other 
mark  be  placed  on  the  negative. 

The  injured  and  corresponding  uninjured  parts  should  be  printed 
and  mounted  side  by  side.  The  printing  should  be  of  equal  and  uniform 
density,  and  upon  it  may  be  written  any  points  that  may  be  of  value  to 
the  judge,  jury,  etc.,  as,  for  instance,  the  diagnosis  of  the  case  in 
question.  Occasionally  a  tracing  upon  the  print  is  permitted  by  the 
lawyer  for  the  defendant. 

C.  How  THE  SKIAGRAPHER  SHOULD  PREPARE  FOR  COURT. 


the  X-ray  witness  is  called  to  court,  it  is  important  that  he 
prepare  himself  thoroughly  with  the  anatomy,  physiology,  and  pathology 
of  t  he  part  involved.  He  should  hold  a  consultation  with  the  medical 
or  >iirgical  expert  who  has  employed  his  services.  In  this  way  a  correct 
opinion  of  the  case  can  be  imparted.  The  skiagrapher  should  have  with 
him  the  negatives  and  prints,  the  result  of  his  X-ray  examination,  to- 
gether with  a  set  of  bones  of  the  part  under  consideration.  When  on 
the  witness  stand,  he  should  be  careful  and  accurate  in  his  statements. 
In  order  that  the  jury  may  fully  comprehend  the  statements  uttered, 
his  answers  should  be  as  free  from  medical  terms  and  technicalities  as 
possible.  Answers  should  always  be  brief  and  to  the  point.  The  witness 
under  cross-exam  ination  should  not  lose  his  temper;  instead,  he  should 


TPIE  ROXTGKX  KAYS  IX  FORENSIC  MEDICINE.          379 

make  every  effort  to  remain  calm  and  self-composed.  Construct  your 
answers  according  to  the  findings  on  the  X-ray  negative.  If  asked  to 
answer  questions  irrelevant  to  the  subject  under  discussion,  or  that  do  not 
relate  to  the  findings  on  the  negative,  the  skiagrapher  should  simply 
answer,  ; '  I  don*  t  know. ' ' 

In  our  present  knowledge  there  are  many  things  that  defy  a  correct 
interpretation  on  the  negative,  and  we  must  frankly  admit  that  fact. 

When  selected  as  an  expert  witness,  the  skiagrapher  should  direct  the 
attorney  employing  his  services,  to  inquire  as  to  the  technic,  data,  etc., 
employed  in  the  production  of  the  X-ray  negative,  and  the  physician  who 
made  the  latter  should  be  cross  examined,  and  not  the  attending  surgeon. 
The  subject  of  a  differential  diagnosis  should  always  be  brought  forward. 

The  following  are  some  of  the  claims  made  by  plaintiffs : 

That  the  physician  or  surgeon  failed  to  properly  diagnose  the  case. 
That  the  attendant  delayed  too  long  in  the  reduction  of  an  unrecognized 
dislocation  or  fracture,  thus  seriously  inconveniencing  the  patient  and 
preventing  his  earning  a  livelihood.  That  by  tardiness  in,  or  total  neg- 
lect of,  reduction,  temporary  or  permanent  disability  has  resulted  in  a 
joint.  That  aukylosis,  neuritis,  or  palsies  have  been  caused  by  splint 
pressure,  or  that  irreparable  damage  has  been  the  outcome  of  callus  for- 
mation in  the  distribution  of  an  important  nerve  trunk.  The  foregoing 
claims  may  be  prevented  if  the  physician  makes  it  a  practice  to  have 
early  and  skilful  skiagrams  of  his  cases,  if  he  gives  guarded  prognoses 
in  all  cases,  and  is  careful  and  scientific  in  his  methods  of  treatment.  "  If 
a  physician  or  surgeon  departs  from  the  generally  approved  methods  of 
practice,  and  the  patient  suffers  an  injury  thereby,  the  medical  prac- 
titioner will  be  held  liable,  no  matter  how  honest  his  intentions  or 
expectations  were  to  benefit  the  patient"  (Taylor). 

The  use  of  the  X-rays  is  so  universally  commended  in  the  modern 
works  on  surgery  and  medicine,  that  the  surgeon  who  fails  to  apply  them 
in  doubtful  cases,  may  justly  be  accused  of  negligent  practice.  In 
medico-legal  cases,  the  X-ray  diagnostician  is  likely  to  be  asked  the 
following  questions : 

1.  Does  the  skiagram  show  fractures  in  all  cases  in  which  they  exist! 
This  question  may  be  answered  thus,  not  only  will  a  fracture  be  shown  in 
almost  all  cases,  but  the  texture  of  the  bone  and  the  relative  densities 
of  the  surrounding  parts  will  also  be  shown,  and  any  disturbance  in  the 
texture  will  be  noticed.    Rupture  of  ligaments,  periosteum,  and  tendons, 
diseased  conditions  of  the  bones,  etc.,  may  also  be  observed,  but  cannot 
be  excluded. 

2.  Does  the  skiagram  show  callus  formation  !     Yes,  it  may  be  seen 
from  the  sixteenth  day  after  the  fracture,  and  up  until  the  time  of  ossi- 
fication, which  may  be  as  late  as  three   months  from  the  time  of  the 
accident.     The  duration  of  this   callus  formation  varies,  according  to 
the  age  and  health  of  the  patient,  whether  the  fracture  is  simple  or 


380  ELECTRO-THERAPEUTICS. 

compound,  its  location,  etc.  When  the  bones  are  in  perfect  apposition, 
callus  formation  will  be  hastened.  Massage  will  also  facilitate  its  produc- 
tion. It  will  be  seen  from  the  foregoing  that  it  is  not  always  easy  to 
predict  how  long  it  will  be  before  callus  will  be  strong  enough  to  sup- 
port the  parts,  but  by  skilful  X-ray  examinations  the  amount  and  density 
of  the  callus  may  be  determined. 

3.  Another  question  often  asked  is,  "  Is  the  fracture  united  or  not  ? " 
The  answer  to  this  question  will  depend  upon  the  age,  general  health, 
local  complications,  and  mode  of  treatment  employed.    By  pressing  upon 
the  bones  and  at  the  same  time  viewing  through  the  fluoroscope,   we 
can  tell  definiteljr  whether  union  is  firm,  and  by  means  of  the  skiagraph 
we  can  tell  the  amount  of  callus. 

4.  In  cases  of  deformity,  we  may  be  confronted  by  the  question, 
"  Was  this  deformity  avoidable  or  not  1 "     The  avoidable  cases  are  those 
resulting  from  an  incorrect  diagnosis  on  the  part  of  the  surgeon,  or  an 
improper  line  of  treatment.     The  unavoidable  cases  are  those  of  oblique 
fracture  where  the  over-riding  of  the  bones  cannot  be  prevented  ;  extra- 
or  intra-capsular  fracture  of  the  head  of  the  femur  in  the  aged,  where 
shortening  is  inevitable ;  in  compound  comminuted  fractures,  where  it 
is  necessary  to  wire  the  ends  of  the  bones,  resulting  in  shortening  ;  and 
in  intra-articular  fractures  often  terminating  in  ankylosis  of  the  joint. 

Functional  disability  and  the  degree  of  visible  deformity  do  not 
bear  any  definite  relation  to  each  other,  as  the  deformity  may  be  great, 
but  the  patient  nevertheless  have  good  use  of  the  part,  and  vice  versd. 

It  is  sometimes  necessary  for  purposes  of  identification  to  reveal  the 
age  of  the  patient  or  of  the  dead  body,  or  to  tell  the  age  of  a  female 
child,  as  in  cases  of  rape,  etc. 

Advantage  is  taken  of  the  fact  that  the  epiphyses  of  the  various  bones 
are  known  to  ossify  at  different  ages,  and  by  making  X-ray  examinations 
of  the  bones,  and  knowing  at  what  period  ossification  takes  place,  an 
approximate  estimate  of  the  age  of  the  individual  may  be  determined. 
The  age  of  a  foetus  can  also  be  discovered  by  this  means.  The  hydro- 
static test  for  the  determination  of  still-born  infants  may  be  corroborated 
by  the  X-rays,  as  the  lungs  will  appear  opaque  if  they  have  never  been 
inflated,  whereas  if  the  infant  has  been  viable  for  some  time,  they  will 
present  more  transparency.  As  an  evidence  of  the  existence  of  death, 
tin-  X-rays  play  an  important  part.  After  death,  the  pulsation  of  the 
heart  is  invisible  and  the  organ  presents  a  sharp  outline.  This  will 
comfort  those  who  are  in  constant  terror  of  premature  burial. 

in  February,  1899,  Dr.  J.  William  White,  Chairman  of  the  Medico- 
legal  Committee  of  the  American  Surgical  Association,  sent  a  circular 
letter  to  each  of  the  members  asking  replies  to  the  following  questions 
concerning  the  value  and  medico-legal  relationship  of  the  X-rays : 

1.  Have  you  found  skiagraphy  reliable  in  the  diagnosis  of  (a) 
fractures  attended  with  so  much  swelling  of  surrounding  tissues  that 


THE  KOXTGEX  KAYS  IX  FOREXSIC  MEDICIXE.          381 

satisfactory  palpation  of  the  fragments  is  impossible?  (6)  Fractures 
about  joints?  (c)  Epiphyseal  separations?  (d)  Fractures  of  the  neck 
of  the  femur?  (e~)  Uuuuited  fractures?  If,  in  any  of  the  cases  belong- 
ing to  one  or  the  other  of  these  classes,  the  skiagraph  was  misleading,  we 
would  like  particularly  to  have  a  print  of  it  and  the  clinical  history  of 
the  case. 

2.  Have  you  any  reliable  cases   of  recognition   of  (a)  fracture  of 
the  base  of  the  skull?      (b)  Fracture  or  dislocation  of  the  vertebrae? 
(c)  Fracture  of  the  sternum,  scapula,  clavicle,  or  pelvis  ! 

3.  Do  you  know  any  of  the  cases  in  which  the  testimony  of  the 
skiagraph  in  cases  of  supposed  foreign  bodies  in  tissues,  or  of  tumors, 
gall    stones    or    kidney    stones,    has    led    to    ineffective    or    mistaken 
operations  ? 

The  conclusions  arrived  at  are  succinctly  stated  as  follows :  "The 
routine  employment  of  the  X-rays  in  cases  of  fracture  is  not  at  present 
of  sufficient  definite  advantage  to  justify  the  teaching  that  it  should  be 
used  in  every  case.  If  the  surgeon  is  in  doubt  as  to  his  diagnosis,  he 
should  make  use  of  this,  as  of  every  other  available  means,  to  add  to  his 
knowledge  of  the  case,  but  even  then  he  should  not  forget  the  grave 
possibilities  of  misinterpretation. 

"  There  is  evidence  that  in  competent  hands  plates  may  be  made  that 
will  foil  to  reveal  the  presence  of  existing  fractures  or  will  appear  to  show 
a  fracture  that  does  not  exist. 

"  In  the  regions  of  the  base  of  the  skull,  the  spine,  the  pelvis,  and 
the  hips,  the  X-ray  results  have  not  as  yet  been  thoroughly  satisfactory, 
although  good  skiagraphs  have  been  made  of  lesions  in  the  last  three 
localities.  On  account  of  the  rarity  of  such  skiagraphs  of  these  parts, 
special  caution  should  be  observed,  when  they  are  affected,  in  basing 
upon  X-ray  testimony  any  important  diagnosis  or  line  of  treatment. 

"As  to  questions  of  deformity,  skiagraphs  alone,  without  expert 
surgical  interpretation,  are  generally  useless  and  frequently  misleading. 
The  appearance  of  deformity  may  be  produced  in  any  normal  bone,  and 
existing  deformity  may  be  grossly  exaggerated. 

"It  is  not  possible  to  distinguish  after  recent  fractures  between  cases 
in  which  perfectly  satisfactory  callus  has  formed  and  cases  which  will  go 
on  to  non-union.  Neither  can  fibrous  union  be  distinguished  from  union 
by  callus  in  which  lime-salts  have  not  yet  been  deposited.  There  is 
abundant  evidence  to  show  that  the  use  of  the  X-rays  in  these  cases 
should  be  regarded  as  merely  the  adjunct  to  other  surgical  methods,  and 
that  its  testimony  is  especially  fallible. 

"The  evidence  as  to  X-ray  burns  seems  to  show  that,  in  the  majority 
of  cases,  they  are  easily  and  certainly  preventable.  The  essential  cause  is 
still  a  matter  of  dispute.  It  seems  not  unlikely,  when  the  strange  suscepti- 
bilities due  to  idiosyncrasy  are  remembered,  that  in  a  small  number  of  cases 
it  may  make  a  given  individual  especially  liable  to  this  form  of  injury. 


182  EL  I  :<  T 1 1(  >-T  1 1 K  H  A  PEUTICS. 

"  In  the  recognition  of  foreign  bodies  the  skiagraph  is  of  the  very 
greatest  value  ;  in  their  local i/.at  ion  it  has  occasionally  failed.  The  mis- 
takes recorded  in  the  former  case  should  easily  have  been  avoided ;  in 
the  latter  they  are  becoming  less  and  less  frequent,  and  by  the  employ- 
ment of  accurate  mathematical  methods  can  probably  in  time  be  elimi- 
nated. In  the  meanwhile,  however,  the  surgeon  who  bases  an  important 
operation  on  the  localization  of  a  foreign  body  buried  in  the  tissues 
should  remember  the  possibility  of  error  that  still  exists. 

''  It  has  not  seemed  worth  while  to  attempt  a  review  of  the  situat  ion 
from  a  strictly  legal  stand-point,  as  different  states  and  different  jndp-s 
vary  in  their  interpretation  of  the  law.  The  evidence  shows,  however, 
that  under  many  differing  circumstances  the  skiagraph  will  undoubtedly 
be  a  factor  in  medico-legal  cases. 

"The  technicalities  of  its  production,  the  manipulation  of  the  appa- 
ratus, etc.,  are  already  in  the  hands  of  specialists,  and  with  that  subject 
also  it  has  not  seemed  worth  while  to  deal.  It  is  earnestly  recommended 
that  the  surgeon  should  so  familiarize  himself  with  the  appearance  of 
skiagraphs,  with  their  distortions,  with  the  relative  values  of  their 
shadows  and  outlines,  as  to  be  himself  the  judge  of  their  teachings,  and 
not  depend  upon  the  interpretation  of  others,  who  may  lack  the  wide 
experience  with  surgical  injury  and  disease  necessary  for  the  correct 
reading  of  these  pictures."  1 

With  the  exception  of  the  statements  that  skiagrams  of  fracture  of 
the  base  of  the  skull  are  unsatisfactory,  and  that  the  detection  of  callus 
formation  and  fibrous  union  in  recent  fractures  is  not  always  possible, 
there  are  few,  if  any,  surgeons  who  to-day  would  endorse  any  such 
conclusions.  More  exact  methods  of  study  and  interpretation  of  nega- 
tives, and  greater  refinements  in  the  necessary  technic  have  made  X-ray 
examinations  and  applications  invaluable  aids  in  medicine  and  surgery. 
The  very  men  who  in  1899  ascribed  doubtful  value  to  the  X-rays  are 
to-day  its  stanchest  supporters ;  indeed  the  judge  and  jury  will  frown 
upon  a  practitioner  for  negligence  who  has  failed  to  avail  himself  of  this 
most  precise  and  scientific  method  in  any  case  of  doubtful  diagnosis, 
where,  through  its  agency,  practical  results  might  have  been  procured. 

II.  The  Physician's  Responsibility  in  Cases  of  X-Ray  Burns. 

X-ray  burns  are  divided  into  two  great  classes  :  Those  produced 
during  an  examination  for  diagnostic  purposes  and  those  brought  about 
by  irradiation  for  therapeusis.  Shortly  after  the  discovery  of  the  X-rays, 
the  use  of  this  agent  in  diagnosis  was  not  infrequently  followed  by  a  der- 
mal it  is.  the  result  of  inadequate  apparatus,  fewer  refinements  in  technic, 
and  a  limited  experience  in  the  application  of  the  new  agent.  But  in 
spite  of  these  various  factors,  the  most  successful,  the  most  skilled,  and 

1  The  American  Journal  of  the  Medical  Sciences,  July,  1900. 


THE  ROXTGEX  BAYS  IX  FOKKXSir  MKDICINE.          383 

the  most  earnest  student  of  the  X-rays,  with  the  best  and  most  modern 
apparatus,  is  liable  at  times  to  produce  a  dermatitis,  for  who  can  s:iy 
which  of  us  are  victims  of  idiosyncrasy,  or  who  knows  the  exact  nature, 
chemical  and  otherwise,  of  the  X-rays? 

When  a  patient  applies  for  X-ray  treatment,  the  skiagrapher  should 
mention  the  possibility  of  a  burn,  and  he  should  either  administer  the 
treatment  himself  or  have  it  given  under  his  direct  supervision. 

With  idiosyncrasy  and  no  exact  measurement  of  dosage,  the  X-ray 
specialist  who  follows  the  established  rules  laid  down  by  his  confreres, 
and  by  experience,  is  taking  the  safest  and  the  oul}r  rational  course. 

This  subject  is  best  treated  of  by  a  recital  of  the  more  important 
cases  wherein  damages  have  been  asked  by  the  complainant,  urging  care- 
lessness, negligence,  or  incornpeteucy  upon  the  part  of  the  radiologist. 

In  a  suit  against  Dr.  Samuel  Lloyd,  of  the  Post-Graduate  Hospital, 
thr  patient  iraa  warned  of  the  danger  of  a  burn.  Two  radiographs  were 
taken,  when  a  diagnosis  of  appendicitis  was  made.  Later  the  patient 
complained  of  an  X-ray  burn  prior  to  the  operation.  The  operation  dis- 
closed an  appendicitis  of  an  advanced  type.  The  suit  was  to  recover 
$50,000  damages  for  the  ''burn/'  The  contention  of  the  defence  was  that 
the  dermatitis  from  which  the  plaintiff  suffered  came  from  the  antiseptic 
preparation  for  the  operation  for  appendicitis,  and  not  from  the  rays. 
The  case,  however,  never  came  to  trial. 

In  October,  1897,  Dr.  Frank  Boyd1  was  made  the  defendant  in  a 
damage  suit  for  producing  a  severe  dermatitis  with  the  rays,  the  plain- 
tiff averring  that  carelessness  was  largely  the  cause  of  the  dermatitis,  as 
well  as  an  insufficient  understanding  of  the  rays  at  that  early  period 
of  their  employment.  The  verdict  rendered  was  in  favor  of  the 
defendant,  the  court  holding  that  in  this,  as  in  other  cases,  the  physician 
was  bound  to  use  ordinary  skill  and  judgment,  placing  the  case  upon 
the  same  footing  as  chloroform  anaesthesia. 

In  the  case  of  Henslin  vs.  Wheaton,  the  Supreme  Court  of  Minnesota 
maintains  that  in  an  action  for  negligence  and  unskilfulness,  the  rule  of 
liability  is  the  same  as  that  applied  to  other  actions  for  malpractice,  and 
one  of  ordinary  care  and  prudence.  '  Being  the  first  case  of  its  kind  in 
Minnesota,  the  judge  remarked  that  no  rule  of  care  in  such  cases  had 
been  laid  down.  But  there  can  be  no  doubt  that  the  rule  applicable  to 
the  care  and  skill  required  of  physicians  toward  their  patients  in  other 
cases  applies.  That  rule  was  stated  in  Martin  vs.  Courtney,  87  Minn.  197, 
in  the  following  language  :  "The  legal  obligation  of  the  physician  to  his 
patient,  where  his  conduct  is  questioned  in  an  action  of  this  character, 
demands  of  him  no  more  than  the  exercise  of  such  reasonable  care  and 
skill  as  is  usually  given  by  physicians  and  surgeons  in  good  standing." 

The  plaintiff  testified  that  the  exposure  of  his  person  to  the  rays  was 

'Journal  of  the  American  Medical  Association,  February  12,  1898. 


884  ELECTRO-THERAPEUTICS. 

for  too  long  a  period  of  time  (30  to  40  minutes),  and  that  the  tube  was 
placed  too  close  to  his  body  (two  inches,  except  at  one  visit,  when  it  was 
placed  more  distant). 

The  foundation  was  fully  laid  for  the  opinion  of  an  expert  touching 
the  questions  involved  in  the  case.  But  the  expert  was  not  a  physician 
and  surgeon,  and  the  defendant  raised  the  objection  that  only  one  was 
qualified  to  testify  against  him,  under  the  rule  pronounced  in  the  case  of 
Martin  r.s.  Courtney,  75  Minn.  255,  where  it  was  held  that  in  an  action 
against  a  physician  or  surgeon  for  malpractice,  unskilful  ness  in  treat- 
ment being  charged,  the  physician  was  entitled  to  have  the  propriety  of 
his  treatment  tested  by  physicians  of  the  same  school.  The  trial  court 
applied  that  rule  to  this  case,  but  the  Supreme  Court  was  of  the  opinion 
that  it  erred,  contending  that  the  application  of  the  rays  to  the  complain- 
ant was  not  for  the  purpose  of  treating  any  disease  or  ailment  from  which 
he  suffered,  but  for  the  location  of  a  foreign  substance,  thought  to  be  in 
his  lungs  (the  gold  crown  of  a  tooth). 

In  the  Courtney  case,  mentioned  above,  it  was  contended  that  the 
apparatus  for  the  generation  of  the  rays,  likewise  the  fluoroscope,  has 
been  used  very  generally  by  electricians,  physicists,  skiagraphers,  physi- 
cians, and  others  for  experimental  and  demonstrative  purposes.  It  is  a 
scientific  and  mechanical  appliance,  the  operation  of  which  is  the  same 
in  the  hands  of  all.  It  may  be  applied  by  any  person  possessing  the  req- 
uisite knowledge,  and  there  would  seem  to  be  no  reason  why  its  appli- 
cation to  the  human  body  may  not  be  explained  by  any  person  who 
understands  it.  The  rule  in  the  Courtney  case  could  therefore  have  no 
application  to  the  case  being  tried.  For  in  the  latter,  the  rays  were  not 
applied  as  a  remedial  agent,  but  for  the  scientific  purpose  of  discovering 
the  presence  of  a  foreign  substance  in  the  lungs.  A  physician,  therefore, 
who  applies  the  X-rays,  not  for  medical  purposes,  but  to  locate  a  for- 
eign substance,  is  not  entitled  to  have  the  question  of  his  care  and  skill 
determined  only  by  the  opinions  of  physicians  of  his  own  school. 

A  suit  of  unusual  interest  has  lately  been  heard  in  the  high  courts. 
A  child  supposed  to  have  run  a  needle  into  his  knee  received  repeated 
X  lay  examinations.  Xo  needle  was  discovered.  A  severe  X-ray  burn, 
resulting  in  an  ulcer,  appeared  on  the  inner  side  of  the  knee,  which  took 
several  months  to  heal.  The  examinations  were  made  by  a  mechanic, 
under  the  supervision  of  a  medical  man  who  had  not  a  practical  knowl- 
edge of  radiography.  It  appears  also  that  he  did  not  recognize  the  ulcer 
a>  an  X-ray  burn,  but  after  its  formation  continued  his  examinations. 
Discovering  the  cause  of  the  injury,  the  child's  parents  asked  damages 
for  alleged  neglect  on  the  part  of  the  defendant.  The  trial  lasted  seven 
days.  Assuming  the  truth  of  the  statement  of  the  child's  relatives,  that 
the  tube  had  been  held  close  to  the  knee  for  periods  of  a  half  hour,  the 
experts  on  one  side  gave  their  opinion  that  such  application  showed 
ni'glijjence.  On  the  other  hand  it  was  maintained  that  the  tube  never 


THE  ROXTGEX  RAYS  IX  FOIJKXSK'  MEDICINE.  385 

came  nearer  the  knee  than  eight  or  ten  inches,  and  from  the  radio- 
graphs produced,  it  was  held  by  experts  that  the  distance  of  exposure 
must  have  been  eight  inches.  The  jury  returned  a  verdict  for  the 
defendants  on  every  count,  finding  that  there  was  no  negligence. 

In  the  United  States  a  suit  was  brought  for  $25,000  damages  against 
Dr.  Otto  Smith  and  Professor  AV.  C.  Fuchs,  of  Chicago.1  The  plaintiff, 
aged  37,  broke  his  right  ankle  as  the  result  of  an  accident  on  September 
2,  1895.  He  was  able  to  attend  his  business  on  May  1,  1896,  and  was 
then  practically  as  well  as  ever.  He  only  suffered  from  slight  stiffness 
and  occasional  swelling  in  the  ankle.  On  September  19,  1896,  X-ray 
photographs  were  made,  each  sitting  occupying  from  thirty-five  to  forty 
minutes,  the  tube  being  placed  five  or  six  inches'from  the  ankle.  While 
under  the  exposure  the  patient  complained  of  sharp,  tingling  pains. 
Three  days  after,  a  slight  redness  appeared  between  the  big  toe  and  the 
adjoining  one,  which  in  three  weeks  had  spread  over  almost  the  entire 
dorsum  of  the  foot,  later  forming  a  blister.  An  intensely  painful  ulcer 
formed,  for  which  condition  amputation  of  the  foot  was  performed.  The 
jury  awarded  the  plaintiff  a  verdict  for  $10,000. 

A  rather  remarkable  case  was  that  of  a  man  named  Shelly,  who 
brought  suit  against  Dr.  G.  AV.  Spohn,  of  Indiana,  claiming  $10,000 
damages  for  X-ray  burns  upon  his  face  and  left  hand.  The  patient 
was  treated  for  a  cancerous  growth  on  the  under  part  of  his  tongue. 
He  was  warned  of  the  possibility  of  a  burn  before  the  treatment  was 
instituted.  After  two  weeks  a  slight  dermatitis  developed  on  the 
patient's  face,  and  the  treatments  were  then  discontinued.  The  patient 
claimed  that  the  doctor  directed  him  to  hold  down  the  lower  jaw  with 
his  left  hand  during  his  treatment.  It  was  proved  on  trial  that  the 
only  real  injury  was  to  the  hand,  and  this  was  shown  to  be  caused  by 
infection  of  a  wound  on  the  hand.  The  hand  became  infected  because 
the  patient  persisted  in  wiping  the  saliva  from  his  mouth,  against  the 
advice  of  his  physician.  The  court  decided  in  favor  of  the  physician.* 

It  will  be  interesting  to  note  briefly  the  views  entertained  and  the 
verdicts  rendered  by  European  jurists.  A  few  are  subjoined. 

Suit  was  instituted  against  "Dr.  Sch."  by  a  lady  whom  he  treated 
for  a  beard-like  growth  on  the  chin.3  A  burn  developed,  involving  not 
only  the  chin,  but  also  the  neck  and  part  of  the  chest.  A  verdict  for 
$75  was  found  against  the  doctor.  He  appealed,  to  have  a  truly  compe- 
tent expert  summoned  to  decide,  naming  Schiff  or  Freund,  of  Vienna. 
He  also  asserted  that  he  was  not  responsible  for  the  devastation  caused 
by  the  burn,  as  it  was  treated  by  other  physicians  who  applied  ichthyol, 

1 A  summary  of  the  case  appears  in  the  American  X-ray  Journal,  St.  Louis,  Mo., 
May.  1SW,  X,).  5,  p.  5GO. 

-Mi'.lk-o- Legal  Bulletin,  January,  1903. 
3  Allg.  meil.  Ct.-Ztg. 


ELECTRO-THERAPEUTICS. 

carbolic  acid,  etc.,  while  experience  has  shown  that  strong  measures  are 
injurious  in  such  cases,  and  that  X-ray  burns  should  be  treated  with 
exceptional  mildness. 

In  France,  a  trial  heard  before  the  Civil  Tribunal  of  the  Seine,  on 
March  8,  1901,  resulted  in  heavy  damages  for  injury  following  the  appli- 
cation of  the  X-rays.1  In  delivering  judgment  the  court  found  that 
Madame  Macquaire  suffered  from  osteitis  of  the  femur,  and  was  referred 
to  Dr.  Renault  for  an  X-ray  examination.  Three  exposures  were  made ; 
the  first  lasted  forty  minutes,  the  second,  which  occurred  eight  days  later, 
consumed  forty-five  minutes,  and  the  third,  which  was  given  fifteen  days 
subsequently,  occupied  a  duration  of  one  hour  and  a  quarter.  A  slight 
erythema  was  noticed  before  the  third  sitting.  The  three  exposures, 
which  gave  a  negative  diagnosis,  were  followed  by  a  deep  burn  of  the 
abdomen  that  necessitated  treatment  for  two  years.  A  scientific  report 
of  the  case  was  presented  to  the  court  by  Professor  Brouardel,  ulio 
stated  that  the  operator's  apparatus,  which  at  one  time  was  efficient, 
had  outlived  its  usefulness,  and  that  he  had  given  too  long  an  exposure. 

The  court,  commenting  upon  the  defective  methods  employed, 
observed  that  the  defendant  was  called  in  not  as  a  medical  man,  but 
as  an  electrical  specialist,  but  that,  nevertheless,  his  medical  title  had 
gained  the  confidence  of  his  patients.  A  too  long  exposure  was  certainly 
one  cause  of  the  accident.  The  third  exposure  of  an  hour  and  a  quarter 
was  inexcusable,  in  view  of  the  fact  that  the  tissues  had  already  been 
injured  by  a  previous  exposure  a  little  over  half  that  time.  The  con- 
clusion of  the  court  was  that  Dr.  Renault  had  committed  a  grave 
professional  error,  and  he  was  ordered  to  pay  5000  francs  damages. 

The  suit  against  Professor  Hoflfa,  of  Berlin,  the  famous  ortho- 
pedist, became  widely  known  not  only  because  of  the  prominence  of  the 
defendant,  but  more  so  for  the  complicated  etiology  of  the  injury. 

The  patient  suffered  from  ankylosis  of  his  hip,  presumably  after 
coxitis,  for  which  he  was  treated  by  the  Rontgen  rays  under  the  super- 
vision of  an  X-ray  specialist.  Altogether  he  was  exposed  six  times. 
Xo  change  for  the  better  occurring,  the  patient  consulted  Professor 
Hoffa,  who  advised  a  diagnostic  exposure  in  order  to  ascertain  the  con- 
dition of  the  hip-joint.  The  distance  of  the  tube  from  the  abdominal 
integument  was  30  cm.,  the  length  of  exposure  twenty-five  minutes. 
Ten  days  later  extensive  dermatitis  set  in,  which  caused  the  patient  to 
bring  charges  of  criminal  negligence  in  the  treatment.  Professor  Hoffa, 
in  defence,  claimed  that  the  exposure  was  made  according  to  the  prin- 
ciples adopted  by  the  medical  profession,  and  that  furthermore  the  sensi- 
tiveness of  the  skin  was  increased  by  the  previous  irradiations.  The 
district  attorney,  after  having  called  upon  an  expert,  who  sustained 
Professor  Hoffa,  dismissed  the  claim. 

1  Gazette  des  Tribuneaux,  March  9,  1901 ;  and  La  Semaine  M(klicale,  March  13, 
1901,  No.  6,  p.  xlii. 


THE  ROXTGEX  BAYS  IX  FORENSIC  MEDICINE.          387 

At  present,  by  our  greatly  improved  means,  Hoffa  would  not  have 
burned  his  patient,  even  in  spite  of  the  preceding  irritation,  because  he 
would  not  have  been  exposed  for  twenty-five  minutes. 

We  may  safely  expect  that  damage  suits  for  Routgen-ray  burns, 
caused  during  diagnostic  exposures,  will  become  more  and  more  infre- 
quent. But  with  the  employment  of  the  rays  for  therapeutic  purposes, 
burns  have  now  become  a  rather  common  accident.  In  several  instances 
suits  were  brought  against  physicians  on  the  ground  that  they  did  not  use 
the  necessary  means  of  protection  ;  in  most  of  these  cases  the  severe 
character  of  the  diseases  demanded  so  severe  a  treatment  that  burning 
had  to  be  contended  with.  This  fact  alone  is  sufficient  proof  of  the 
perfidious  nature  of  the  suits.  Where  cosmetic  considerations  alone  are 
concerned,  such  heroic  therapy  is  injudicious.1 

A  man  suffering  much  distress2  in  the  early  stage  of  locomotor  ataxia 
was  sent  by  his  physician  to  a  firm  of  chemists  for  treatment  with  the 
X-rays.  The  rays  were  applied  ten  or  eleven  times  and  the  physician 
was  never  present.  The  man  who  administered  the  treatment  often  left 
the  patient  during  the  sitting.  The  machine  emitted  great  sparks  and 
once  or  twice  gave  the  patient  a  shock,  but  being  quite  ignorant  he  made 
no  complaint  to  his  physician.  His  feet  began  to  blister,  for  weeks 
he  suffered  greatly,  and  his  screams  were  such  that  lodgers  left  the 
house.  Eventually,  the  soles  sloughed  off  and  he  became  unable  to 
walk.  He  brought  an  action  for  damages  against  the  firm.  Mr.  Chis- 
holrn  Williams,  superintendent  of  the  X-ray  department  of  the  West 
London  Hospital,  was  called  as  a  witness.  He  said  that  it  was  evident 
that  the  plaintiff  had  been  placed  too  near  the  instrument — 12  or  18  inches 
being  the  proper  distance,  not  2  or  3.  In  cross-examination  he  admitted 
that  the  use  of  the  X-rays  is  a  recent  innovation,  and  that  even  physicians 
are  burned  at  times.  The  plaintiff's  physician  said  that  he  had  never 
administered  the  rays,  and  that  he  had  only  studied  the  subject  from 
books.  He  said  that  he  thoroughly  trusted  the  defendants,  who  had 
often  administered  the  treatment  for  him,  merely  telling  them  the  part 
to  which  the  rays  were  to  be  applied.  For  the  defence  it  was  urged 
that  the  defendants  were  not  liable  for  mistakes  of  the  physician.  Wit- 
nesses were  called  to  show  that  it  is  essential  that  a  physician  should  be 
present  as  well  as  the  person  who  administers  the  treatment.  The 
defendants  stated  that  they  had  not  studied  the  properties  of  the  rays  or 
administered  them  from  a  therapeutic  point  of  view.  The  jury  returned 
a  verdict  for  the  defendants. 

Medico-legal  Aspect  of  X-ray  Sterility. — Destruction  of  the  procreative 
capacity  by  means  of  applications  of  the  Rontgen  rays  may  perhaps 

'Quoted  from  an  interesting  article  on  "The  Medico-legal  Aspect  of  Accidents 
caused  by  the  Rontgen  Rays,"  by  Carl  Beck,  M.D.,  in  American  Medicine,  April  16, 
1904. 

2  Journal  American  Medical  Association,  August  10,  1906. 


;;,x>  ELEOTRO-T 1 1 K I  { A I  >E  \"V\  CS. 

prove  of  frequent  occurrence  if  the  use  of  the  apparatus  by  anybody  and 
everybody  continues  to  be  permitted.  The  matter  was  brought  up  by  M. 
Hennecart  at  the  Rontgen  Bay  Congress  recently  held  in  Berlin.1  He 
advocated  legislation  restricting  to  physicians  the  use  of  the  rays  on  human 
beings,  arguing  that  it  would  be  difficult  to  punish  laymen  in  the  event 
of  avoidable  injury.  He  met  with  hearty  support  in  his  contention, 
and,  on  motion  of  Dr.  Becher,  of  Berlin,  a  resolution  was  adopted  calling 
upon  physicians  to  employ  only  medical  men  in  X-ray  work,  pending 
legislation  on  the  subject. 

A  committee  was  recently  appointed  by  the  Paris  Academic  de 
M&lecine  to  report  on  the  question  whether  the  medical  use  of  the  Kont- 
gen rays  should  be  restricted.  They  emphatically  advocate  that  the 
medical  application  of  the  Kontgen  rays  should  be  legally  restricted  to 
duly  qualified  persons.  Their  conclusions  are  based  on  the  established 
facts  that  the  medical  use  of  the  Rontgen  rays  may  lead  to  serious  acci- 
dents, and  that  certain  practices  may  prove  a  social  danger,  while,  on 
the  other  hand,  only  qualified  physicians  or  health  officers,  or  regularly 
licensed  dentists  (in  the  domain  of  odontology),  are  capable  of  interpret- 
ing the  results  obtained  from  the  point  of  view  of  the  diagnosis  and  treat- 
ment of  affections.1 

1  Presse  nuVlicale,  May  13,  1905. 

J  Arch.  d'Electricite  inedicale,  February  10, 1906. 


PART  III 

RADIOTHERAPY,   RADIUM,  AND    PHOTOTHERAPY. 


THE  invaluable  services  rendered  by  X-rays  in  numerous  affections, 
notably  in  epithelioma  and  other  cutaneous  lesions,  are  too  well  known 
to  need  elaboration.  The  action  of  the  rays  upon  malignant  disease 
of  the  deeper  structures  offers  to  the  profession  less  promise  of  marked 
good  than  in  the  superficial  variety.  In  tuberculosis,  leukaemia,  and  in 
diseases  and  affections  of  a  systemic  nature,  time  alone  will  be  the  deter- 
mining factor.  As  assertions  without  proofs  must  weaken  any  statement, 
the  following  portion  of  the  work  is  devoted  to  the  therapeutic  action 
of  this  agent,  its  uses,  its  limitations,  its  disadvantages,  from  which 
the  reader  can  glean  more  information  and  arrive  at  more  decided 
(•(inclusions,  than  by  the  recital  of  a  number  of  theories,  that  at  best 
would  be  inexact,  hypothetical,  and  abstract. 


CHAPTER   I 
ACTION  OF  THE  X-RAYS  ON  BACTERIA. 

THE  results  obtained  by  investigators  on  the  question  of  the  bacteri- 
cidal power  of  the  X-rays  seem  coufusingly  contradictory  in  many  ways. 

There  are  a  number  of  authorities  who,  from  clinical  experience 
with  the  action  of  the  X-rays  on  bacteria,  firmly  believe  that  the  action 
of  the  rays  upon  certain  of  the  micro-organisms  is  in  the  main  detri- 
mental to  their  development,  and  that  destruction  results  from  a  few  or 
more  applications. 

In  March,  1896,  Dr.  "VV.  W.  Keen1  reported  the  results  obtained  by 
the  action  of  the  rays  on  the  pink-hued  streptococcus,  bacillus  anthra- 
cosis,  micrococcus  prodigiosus,  yellow  sarcina,  the  tubercle  bacillus,  etc. 
He  asserts  that  after  exposures,  first,  for  half  an  hour,  and  then  twice  for 
fifteen  minutes,  neither  lethal  nor  inhibitory  effects  resulted  upon  the 
cultures.  Dr.  Davis,  a  few  months  prior  to  Dr.  Keen's  report,  published 
exactly  similar  results,  the  latter's  report  confirming  what  had  already 
been  stated  by  Dr.  Davis. 

Berton  2  reports  that  he  exposed  cultures  of  the  Klebs-Loffler  bacilli, 
on  bouillon,  to  the  action  of  the  X-rays  for  periods  of  sixteen,  thirty-two, 

1  The  American  Journal  of  the  Medical  Sciences. 
'Bull.  Gen.  de  Therap.  November  8, 1896. 

389 


390  ELECTRO-THERAPEUTICS. 

and  sixty- four  hours,  but  in  no  instance  was  he  able  to  observe  any 
result  on  the  vital  manifestations  of  the  various  inicro-organisuis. 

Wittlin,  Wolff,  Grumniach,  and  many  others  have  made  experiments 
on  various  types  of  bacteria,  the  results  on  the  whole  being  negative. 

Muhsam l  reports  that  general  tuberculosis  in  the  guinea-pig  is  not 
affected  by  the  X-rays,  whilst  to  a  certain  extent  a  localized  tuberculosis 
is  hindered  in  its  development. 

Sormani  *  reports  that  he  exposed  numerous  cultures  of  bacteria 
for  six  hours  to  the  action  of  the  X-rays,  at  a  distance  of  from  one 
to  two  inches.  No  alteration  in  the  rapidity  or  mode  of  development, 
in  the  formation  of  gas,  or  in  their  color,  fluorescence,  or  virulence 
was  noted. 

J.  Brunton  Blaikie*  concludes  that  the  rays  have  no  visible  influence 
on  the  growth  of  cultures  of  the  tubercle  bacillus,  and  that  the  chemical 
constitution  of  diphtheria  toxin,  like  the  delicate  chemical  structure  of 
the  retina,  is  not  affected  by  their  vibrations. 

Gocht4  reports  the  results  of  Minck's  experiments.  In  his  investi- 
gations Miiick  found  that  sunlight,  daylight,  and  arc-light  caused  a  weak- 
ened condition,  amounting  to  injury  to  the  bacteria  in  cultures.  He 
exposed  agar  plates  of  typhoid  bacilli  to  the  rays  for  thirty  minutes,  with- 
out any  injurious  effects.  By  these  experiments  he  proved  that  a  fewer 
number  of  typhoid  colonies  developed  on  that  part  of  the  plate  exposed 
to  the  influence  of  the  rays  than  on  that  portion  not  so  exposed.  In 
Minck's  later  reports  he  specifies  that  no  bad  effects  were  produced  on 
the  typhoid  bacteria  when  they  were  exposed  to  the  action  of  the  rays 
for  eight  consecutive  hours. 

H.  Rieder 5  reports  the  experiments  performed  by  Schultze  and  Beck 
upon  bacteria  with  color-producing  abilities.  The  micro-organisms  were 
planted  in  agar-agar  soil  on  Petri  dishes  and  exposed  from  thirty  min- 
utes to  two  and  a  half  hours  to  the  influences  of  the  Rontgeu  rays.  It 
was  shown  that  after  twenty-four  hours'  exposure,  the  bacteria  had  thrived 
quite  considerably,  also  that  those  shielded  by  lead,  from  the  full  action 
of  the  rays,  produced  the  same  color  as  those  that  were  subjected  to  the 
full  action  of  the  rays.  In  the  experiments  a  coil  of  12  cm.  spark  length 
was  used,  and  the  tube  containing  the  bacteria  was  25  cm.  distant  from 
the  source  of  the  rays.  He  concludes  that  the  rays  are  negative  as 
regards  chromogenic  or  color- producing  effect  of  micro-organisms,  and 
that  they  cause  a  more  rapid  sporulation  of  the  bacillus  subtil  is,  while 
retarding  that  of  the  bacillus  anthracis. 

'Freie  Vereining.  d.  Chir.,  1898. 

*<;iorno  della  v.  soc.  it.  dig.,  May  and  June,  1896. 

'The  Scottish  Medical  and  Surgical  Journal,  May,  1897. 

4  Fortschritte  a.  d.  Geb.  d.  Runtgenstr.,  B.  L,  1897-1898,  page  34. 

'Munchener  med.  Wochenschrift,  1898,  No.  4,  101-104. 


ACTIOX  OF  THE  X-RAYS  ON  BACTERIA.  391 

Drs.  Xorris  "\Volfenden  and  Forbes  Ross  1  conducted  experiments 
with  the  bacillus  prodigiosus.  They  grew  cultures  on  potato,  carrying 
the  same  to  the  fifth  generation.  When  exposed  to  the  rays  for  a  period 
of  sixty  minutes,  there  was  a  great  increase  of  growth  as  well  as  of  the 
pigment  production.  An  18-inch  spark  producing  coil  was  used,  16 
volts,  with  an  amperage  from  8  to  10.  The  culture  was  placed  6  or  8 
inches  distant  from  the  vacuum  tube.  The  same  investigators  observed 
only  very  slight  changes  in  the  protococcus. 

Sabrazes  and  Riviere2  report  the  result  of  their  experiments  con- 
ducted with  the  bacillus  prodigiosus.  The  culture  was  placed  15  cm. 
distant  from  the  vacuum  tube,  the  dishes  being  covered  with  black  paper, 
so  as  to  exclude  all  possible  light.  They  observed  no  changes  in  the 
chromogenic  ability  of  the  bacilli ;  the  morphological  characteristics, 
growth  in  particular,  remained  undisturbed  by  a  daily  hour  exposure  for 
20  consecutive  days.  They  also  performed  experiments  with  the  rays  on 
the  heart  of  a  frog  and  also  upon  the  leucocytes,  failing,  however,  to  ob- 
serve any  important  changes  when  the  exposure  lasted  from  20  minutes 
to  one  hour  or  even  longer. 

Schaudiim 3  experimented  on  various  types  of  unicellular  organisms, 
showing  that  the  protozoa  differ  greatly  in  their  reaction  to  the  rays. 
These  differences  depend  possibly  on  the  varying  conditions  of  the  nuclei, 
and  on  the  presence  or  absence  of  capsules. 

Dr.  F.  Robert  Zeit,  of  the  Xorth-Western  University,4  gives  the 
result  of  experiments  upon  various  forms  of  micro-organisms,  and  arrives 
at  the  following  conclusions  : 

"Bouillon  and  hydrocele- fluid  cultures  in  test- tubes,  or  non- 
resistant  forms  of  bacteria,  could  not  be  killed  by  the  action  of  the 
rays  after  48  hours'  exposure,  and  at  a  distance  of  20  mm.  from  the 
X-ray  tube. 

"  Suspensions  of  bacteria  in  agar-agar  plates  exposed  for  a  period  of 
four  hours  to  the  rays,  according  to  the  plans  carried  out  by  Rieder, 
were  not  killed. 

' '  Tuberculous  sputum,  even  when  exposed  to  the  Rontgen  rays  for 
six  hours,  at  a  distance  of  from  16  to  22  mm.  from  the  tube,  caused 
acute  miliary  tuberculosis  of  all  the  guinea-pigs  so  inoculated.  Rontgen 
rays  have  no  direct  bactericidal  properties." 

Lortet  and  Geuoud,5  Fiorentini  and  Liuaschi,6  report  an  arrest  of 
development  of  the  bacilli  in  the  guinea-pig. 

1  Lancet,  1898,  p.  1752. 

1  Comptes-rend.  Acad.  d.  Sc.  Paris,  1897,  cxxiv.  p.  979-982. 

'Pfliiger's  Archiv  f.  d.  ges.  Physiologic,  1899  ;  Archives  d'Electricite  Med.,  No. 
80,  1900. 

4  Journal  of  the  American  Medical  Association,  1901,  xxxvii.  p.  1432. 

5  Comptes-rendus,  1896. 
•British  Medical  Journal,  1897. 


392  KLECTRO-THERAPEUTICS. 

Rieder1  has  reported  quite  elaborately  on  this  subject.  He  used 
Volt-Ohm  tubes,  and  a  coil  of  12  inches  (30  cm.)  spark  length.  The 
distance  of  the  anticathode  from  the  cultures  was  four  inches,  and  the 
exposure  was  from  one  to  three  hours.  The  cultures  were  covered  by 
a  leaden  plate  having  a  central  aperture,  so  that  the  exposed  part  might 
be  readily  compared  with  the  unexposed  area.  An  apir  plate  culture  of 
cholera  vibrio  was  then  placed  in  an  incubator  kept  at  a  temperature  of 
37°  C.  after  it  had  been  exposed  to  the  action  of  the  rays  for  forty-five 
minutes.  In  the  incubator  was  also  placed  a  control  culture  plate,  which 
had  not  been  exposed  to  the  rays.  On  the  exposed  plate,  the  colonies 
were  markedly  fewer  in  number  than  on  the  unexposed  plate.  Similar 
experiments  were  made  with  gelatine  cultures  of  the  bacterium  coli, 
staphylococcus  pyogenes  aureus,  streptococcus,  bacilli  of  anthrax,  and 
other  bacilli.  The  tubercle  bacilli,  in  meat  extract,  glycerin,  and  solution 
of  peptone,  were  similarly  affected. 

In  consequence  of  the  bactericidal  action  of  the  Rontgen  rays  on 
plate  cultures,  he  made  further  experiments  on  animals.  Mice,  rabbits, 
and  guinea-pigs  were  inoculated  with  the  bacilli  of  anthrax,  streptococcus, 
and  staphylococcus,  and  directly  after  injection  they  were  subjected  to 
action  of  the  rays.  The  results  being  negative,  he  believed  that  the  rays 
have  no  effect  on  acute  infectious  processes. 

In  order  to  study  its  action  in  chronic  affections,  Rieder  experi- 
mented on  animals  with  tubercle  bacilli.  After  subjecting  them  to  the 
action  of  the  rays,  uecrotic  destruction  of  the  skin  was  observed.  This 
came  on  very  gradually,  remained  for  a  considerable  period  unaltered, 
and  showed  little  or  no  tendency  to  extend.  The  affected  skin  was  covered 
with  seal >>.  and  slight  swelling  and  encapsulation  of  the  tuberculous  foci 
were  likewise  observed.  In  the  control  cases,  the  skin  showed  the  pres- 
ence of  ulcers  as  if  made  by  a  therrno-cautery,  and  these  had  a  decided 
tendency  to  increase  in  area.  Disease  of  the  internal  organs  set  in 
later,  in  those  animals  which  had  been  exposed  to  the  rays.  That  local 
tuberculosis  was  arrested  by  the  rays,  and  in  many  cases  the  general  in- 
fection retarded,  was  proved  conclusively,  but  nevertheless  all  the  animals 
succumbed. 

Rieder's  experiments  proved  that  the  bacteria,  when  grown  on  agar- 
agar,  blood  serum,  or  gelatine,  were  killed  when  exposed  to  the  action  of 
the  rays  for  one  hour  or  more.  When  bacteria  developed  in  suitable  media 
outside  of  the  body,  their  ability  to  develop  further  can  be  stopped,  or  at 
least  discontinued  to  a  degree,  or  even  killed,  by  exposing  them  to  the 
action  of  the  rays.  He  proceeds  to  say  that  it  may  be  unnecessary  to  kill 
the  various  bacteria  inhabiting  the  human  body,  but  only  to  inhibit  their 
growth  and  reproduction. 

1  Miineh.  im-.l.  Wochenschrift,  1898,  No.  4,  S.  101;  and  No.  25,  S.  773  ;  1899,  No.  10  ; 
an«l  No.  29,  S.  250. 


ACTION  OF  THE  X-RAYS  OX  BACTERIA.  393 

In  experiments  on  developed  germ  colonies  he  found  that  cholera 
micro-organisms  were  killed  after  they  had  been  exposed  to  the  rays  for 
a  period  of  two  hours  or  longer.  Gelatine  cultures  of  the  bacillus  coli, 
which  had  previously  been  in  an  incubator  for  from  IL*  to  24  hours  and 
then  subjected  to  the  rays,  showed  colonies  in  the  exposed  portion  of 
the  dish  which  proved  to  be  quite  as  large  as  those  which  were  pro- 
tected during  the  exposure  from  the  influence  of  the  rays,  though  they 
were  diminished  in  number. 

In  another  experiment  Rieder  employed  eight  dishes  of  extract  of 
beef,  glycerin,  and  peptone  solution,  prepared  with  a  thin  layer  of  new 
tubercle  bouillon  culture,  exposing  four  dishes  to  the  rays  for  a  period  of 
a  little  over  an  hour.  These  dishes  together  with  those  non-exposed  were 
placed  in  an  incubator  at  a  temperature  of  37°  C.  One  week  following 
he  observed  a  luxuriant  growth  of  the  tubercle  bacilli  in  the  unexposed 
dishes,  and  in  three  of  the  exposed  dishes  he  observed  a  diminished 
growth,  while  in  the  fourth  dish  there  was  hardly  any  growth  at  all 
discernible. 

Rudis-Jicinsky  '  states  that  his  results  are  similar  to  those  of  Rieder, 
hence  he  also  favors  the  theory  that  the  X-rays  have  a  destructive  action 
upon  various  bacteria.  In  the  following  table  are  to  be  seen  the  results 
he  has  obtained. 

UNDER  X-RAY  IRRADIATION.  MEDIA. 

ACID.  ALKALINE. 

Bacillus  anthracis Negative,  Negative. 

Bacillus  tuberculosis  (in  sputum). . .  .Destroyed  in  48  minutes,  Negative. 

Bacillus  tuberculosis  (in  flask) Destroyed  in  50  minutes,  GVowth  accentuated. 

Spirillum  cholene  (in  flask ) Destroyed  in  51  minutes,  55  minutes. 

Bacillus  diphtheria?  (in  flask ) Destroyed  in  46  minutes,  48  minutes. 

Bacillus  typho-abdominalis Destroyed  in  45  minutes,  49  minutes. 

Streptococcus Negative,  Negative. 

Staphylococcus Negative,  Negative. 

Mierococcus  pyogenes  albus Negative,  40  minutes. 

Micrococcus  gonorrhoase 'Destroyed  in  35  minutes,  40  minutes. 

The  destruction  of  bacteria  in  cultures  studied  by  careful  observ- 
ers, if  not  due  to  the  direct  action  of  the  rays,  is,  he  believes,  brought 
about  by  electrical  wave  discharges.  The  effect  of  the  X-rays  on  micro- 
organisms in  tissues  endowed  with  life,  is  at  present  an  unsettled  question. 
It  is  admitted  that  the  effects  here  are  different  from  those  upon  bac- 
teria in  cultures.  That  there  is  a  decided  effect  upon  streptococci, 
staphylococci,  and  certain  other  pus-producing  organisms  when  in  living 
diseased  tissues  cannot  be  doubted. 

In  the  treatment  of  abscess,  frequent  irradiations  cause  the  discharge 
to  become  sero-fibrinous  in  character,  and  greatly  relieved  of  bacteria, 

1  New  York  Medical  Journal,  Ixxiii.,  1901,  pp.  364-385. 


394  ELECTEO-THEEAPEUTICS. 

with  a  consequent  decrease  in  the  virulence.  This  proves  that  the 
X-rays  must  have  an  effect  upon  the  bacteria  when  imbedded  in  living 
tissues.  Practically  similar  results  may  be  observed  in  a  superficial 
ulcer,  which  upon  close  microscopical  examination  shows  the  gradual 
disappearance  of  the  pus  micro-organisms.  Ullman,  Sambuc,  Mougour, 
and  many  others  seem  to  be  of  one  opinion,  that  the  rays  cause  a  phagocy- 
tosis ;  but  it  is  now  generally  believed  that  the  rays  produce  an  electro- 
chemic  substance  (an  antiseptic)  in  each  and  every  cell,  which  destroys 
the  germs  and  aids  in  the  healing  process. 


CHAPTER  II 

THE    HISTOLOGICAL    CHANGES    INDUCED    BY   THE  ACTION 
OF  THE  RONTGEN  EAYS. 

AMONG  those  who  have  studied  most  carefully  tissue  changes  the  re- 
sult of  the  action  of  the  rays  are  Gilchrist,  Oudin,  Bartheleniy  and  Dar- 
ier,  Unna,  Gassmann,  Salarnon,  Scholtz,  and  many  others.  Dr.  Kibbe, 
of  Seattle,  perhaps  the  first  investigator  to  report  authentically  upon 
this  subject,1  relates  the  histological  changes  occurring  in  a  piece  of 
inflamed  and  discolored  skin,  removed  without  the  aid  of  local  anaes- 
thesia ;  the  outer  layers  of  the  skin, «.  <?.,  the  rete  mucosum,  presented  the 
most  striking  alterations,  particularly  in  the  nuclei ;  the  latter  were  ob- 
served to  take  hreniatoxylin  and  lithium  carmin  very  feebly,  and  showed 
in  addition  a  peculiar  granularity,  first  indicated  by  the  formation  of  a 
fine  nucleolus,  which  was  seen  here  and  there  in  the  process  of  division. 

Near  the  stratum  granulosuni,  the  bodies  of  the  cells  were  apparently 
becoming  converted  into  keratin  hyalin,  as  a  first  step  to  the  increase  in 
bulk  of  the  stratum  granulosuni,  by  a  development  in  their  interior  of 
coarse  granules,  staining  deeply  with  hgematoxylin  and  also  with  carmin. 
The  corium  exhibited  the  ordinary  changes  found  in  mild  dermatitis, 
— i.  e.,  capillary  dilatation,  with  collections  of  round  cells  scattered 
throughout  its  structure,  particularly  around  the  hair  follicles.  No 
blood  extravasations  in  any  of  the  specimens  had  been  noted  under  the 
miscroscope  or  macroscopically. 

Gilchrist2  gives  the  results  of  his  examination  from  dry,  red,  exfoliat- 
ing dermatitic  areas.  His  report  is  as  follows  :  "Two  portions  of  skin 
were  removed  for  microscopical  study,  on  the  first  day.  One  portion  was 
removed  from  the  dorsum  of  the  phalaugeal  region  of  the  third  finger, 
and  the  other  from  the  lateral  margin  of  the  head,  over  the  base  of  the 
metacarpal  of  the  little  finger.  Neither  stained  nor  unstained  sections 
demonstrated  the  presence  of  any  foreign  particles,  and  only  showed 
chronic  inflammatory  changes.  A  decidedly  large  number  of  brown 
granules  of  melanin  were  found  in  the  desquamating  or  exfoliating  por- 
tion. The  mucous  layer  did  not  appear  to  be  thickened,  though  it  was 
more  pigmeuted  than  normal.  In  the  stratum  corium,  the  blood-vessels 
appeared  irregular  and  dilated,  and  the  pigment  cells  covering  the 
papillae  were  almost  as  numerous  as  are  usually  found  in  the  stratum. 

"It  was  suggested  that  particles  of  platinum  might  have  passed 
from  the  tube  through  the  glass  bulb  and  have  been  deeply  imbedded 

xThe  New  York  Medical  Journal,  1897,  Ixv.  p.  71. 
*  Johns  Hopkins  Hosp.  Bui.,  1897,  viii.  p.  17. 

395 


:*%  ELECTRO-THERAPEUTICS. 

in  the  tissue,  giving  rise  to  pigmentation.  Portions  of  the  exfoliat- 
ing skin  were  accordingly  submitted  to  Professor  Abel  for  a  chemical 
analysis,  who  stated  that  no  particles  of  platinum  could  be  detected." 

Gassmann  and  Schenkel '  made  histological  examinations  of  deraia- 
titic  areas,  and  found  that  the  tissue  was  not  necrotic  but  consisted  of 
easily  stained  elements ;  degenerate  forms  were  observed  like  those 
found  in  pathological  tissue,  which  readily  took  up  the  nuclear  stains. 
These  presented  peculiar  aspects,  some  being  drawn  out  into  long 
threads,  others  were  branched,  indented,  and  grouped  into  irregular  clus- 
ters, while  there  were  also  a  few  large  lymph-vessels  and  capillaries  dis- 
tended with  blood.  Elastic  fibres  were  plentifully  distributed,  together 
with  collections  of  crowded  mononuclear  leucocytes,  and  a  general  but 
minute  extravasation  of  erythrocytes.  It  is  still  undecided  whether  this 
peculiar  tissue  may  be  regarded  as  an  altered  subcutaneous  tissue  or  as 
a  newly  formed  tissue  already  undergoing  degeneration.  The  healing 
process,  which  was  very  slow,  began  at  the  peripheral  margin  of  the 
diseased  area. 

Oudin,  Barthelemy,  and  Darier,1  in  a  study  of  alopecia  in  guinea-pigs, 
found  the  prickle  cell  of  the  stratum  granulosum  ten  to  fifteen  times 
thicker  than  is  normally  the  case,  the  individual  cells  being  only 
slightly  altered.  Xot  a  single  hair  root  was  visible,  and  there  appeared 
only  slight  traces  of  the  previous  hair  follicles.  All  the  hair  papillae, 
regeneration  buds,  and  sebaceous  glands  were  lacking. 

The  changes  in  the  dermis  were  trivial,  the  white  fibrous  and  yellow 
elastic  connective  tissue  network  being  normal  in  texture.  The  large  and 
smaller  blood-vessels  of  both  the  cutis  and  subcutis  were  normal ;  nor 
were  any  changes  in  the  structure  of  the  nerve-fibres  apparent.  These 
writers  conclude  that,  as  a  result  of  intense  irritation,  the  least  differen- 
tiated skin  elements  are  apparently  increased.  On  the  contrary.  Un- 
modified elements,  hair,  nails,  and  glands,  undergo  retrogressive  changes 
and  atrophy.  They  do  not  know  whether  these  changes  are  due  to 
nervous  influence  or  to  obliteration  of  vessels  or  other  circulatory 
disturbances. 

Unna*  reports  his  investigations  on  a  brown  pigmented  skin,  obtained 
from  a  woman  who  had  been,  previous  to  her  disease,  exposed  to  the 
influence  of  the  rays.  He  states  that  no  increase  of  pigment  was  ob- 
served in  the  epidermis,  but  that  there  was  a  decided  increase  of  coloring 
matter  in  the  hair  and  in  the  connective  tissue  of  the  papillary  layer; 
this  appeared  to  be  especially  pronounced  in  the  immediate  vicinity 
surrounding  the  capillaries  and  the  more  superficial  layers  of  the  cutis. 

1  Kortsdiritte.  Bin  Beitrag  zur  Behandlung  der  Hautkrankheiten  mittels  Ront- 
genstrahlfii,  vol.  ii.  p.  128. 

-  M«.natach.f.  prakt.  Derm.,  1897,  xxv.  p.  417. 
"Deutech.  med.  Ztng.,  1898,  xviii.  p.  l«.»7. 


ACTIOX  OP  THE  BONTGEN  EAYS.  397 

Scholtz1  says:  ''In  almost  every  field  were  cells  with  nuclei  divided 
into  two  or  three  parts  without  any  attempt  at  karyomitosis.  The  evi- 
dences of  a  beginning  degeneration  were  apparently  everywhere.  The 
outlines  of  the  cells  were  hardly  distinguishable,  and  their  protoplasm 
appeared  blended  into  a  homogeneous  mass.  The  nuclei  were  merely 
shadows.  In  the  hair  follicles  and  sheaths,  the  changes  in  the  cells 
appeared  entirely  analogous ;  and  the  loosening  and  falling  of  the  hairs 
can  be  easily  understood  when  taking  into  consideration  this  active  cell 
degeneration. 

"The  corium  was  oedematous ;  the  connective  tissue  fibres  did  not 
stain  well,  and  appeared  somewhat  swollen  and  homogeneous.  The 
basophilic  reaction,  of  which  Unna  speaks,  could  not  be  demonstrated, 
though  the  elastic  reticuluiu  was  still  intact.  Xo  appreciable  changes 
were  apparent  in  the  small  vessels.  Evidences  of  inflammatory  reaction 
were  only  slightly  intimated.  The  connective  tissue  cells  and  the  sweat 
glands  showed  changes  only  to  a  slight  degree.  The  cells  of  the  intima 
were  swollen,  projected  into  the  lumen  of  the  vessels,  and  in  some  places 
showed  evident  proliferation,  with  a  tendency  to  fall  off  into  the  blood 
current." 

Gassmann2  described  the  changes  occurring  in  the  larger  and 
smaller  blood-vessels  of  a  part  subjected  to  the  action  of  the  X-rays,  as 
follows  : 

"  Important  changes  are  noticeable  in  the  vessels.  The  walls  of  the 
small  vessels  and  capillaries  in  the  upper  zone  of  an  ulcer  are  changed 
into  an  irregular  swollen  mass,  the  lumen  being  sometimes  entirely 
obliterated,  and  sometimes  filled  with  corpuscles,  in  which  latter  case  the 
vessel  is  surrounded  by  a  collection  of  infiltrating  cells.  The  intima  is 
thickened  and  the  eudothelial  cells  are  swollen,  and  often  detached  from 
the  wall. 

"The  small  vessels  of  the  deeper  tissues  show  similar  changes  of  the 
intima,  the  lumen  being  entirely  or  partly  obliterated.  In  the  larger 
an  cries  and  veins  of  the  subcutis  the  intima  is  thickened,  there  is 
proliferation  of  the  eudothelial  cells,  filling  perhaps  half  of  the  lumen. 
The  intima  shows  numerous  vacuoles  and  crevices.  The  muscular  layer 
also  shows  vacuoles ;  the  cells  seem  to  be  pressed  together,  are  smaller, 
and  the  fibres  between  them  do  not  stain  well. 

"Leucocytes  are  present  in  the  media,  and  more  numerously  in  the 
adventitia.  Xeither  the  inner  nor  the  outer  elastic  layers  are  compact, 
but  both  are  loose,  the  fibres  separated  from  each  other  by  spaces  and 
increased  in  number.  Xot  all,  but  many,  of  the  large  vessels  show  these 
changes.  The  lumiua  are  sometimes  empty,  though  not  obliterated, 
sometimes  filled  with  blood." 

1  Arcli.  f.  Derm.  u.  Syph.  1902,  lix.  p.  241. 

"Fortschr.  a.  d.  Geb.  Runtgenstrahlen,  1899,  11,  p.  199. 


ELECTRO-THERAPEUTICS. 

I.  The  Action  of  the  X-rays  on  the  Skin,  or  Rontgen  Dermatitis. 

That  the  X-rays  have  an  effect  upon  normal  as  well  as  on  pathologi- 
cal tissues  is  to-day  an  established  fact.  They  cause  changes  not  only  in 
the  superficial  but  also  in  the  deeper  structures.  In  the  former  we  refer 
to  changes  in  the  several  parts  of  the  skin  and  the  subcutaneous  tissue  ; 
in  the  latter  we  allude  to  possible  changes  produced  in  organs  such 
as  the  lungs,  heart,  kidneys,  and  other  viscera. 

Shortly  after  the  discovery  and  application  of  the  rays  for  diagnostic 
purposes,  it  was  noted  that  in  some  of  the  cases,  a  dermatitis  of  varying 
severity,  with  epilation  of  the  hair  occurred.  This  untoward  incident 
was  the  genesis  of  X-ray  therapy. 

A.  CAUSES  OF  X-RAY  DERMATITIS. 

Many  theories  have  been  advanced  regarding  the  etiology  of  X-ray 
dermatitis.  Prominent  among  these  are  the  following  : 

1.  Flight  of  minute  platinum  atoms. 

2.  Ultra-violet  rays. 

3.  Cathode  rays. 

4.  Rontgen  rays. 

5.  Electrical  induction. 

6.  Ozone  generation  in  the  skin. 

7.  Idiosyncrasy. 

8.  Faulty  technic. 

1.  This  theory  lacks  confirmation  and  is  not  generally  accepted. 

2.  Stine1  and  Goldstein2  state  that  burns  received  on  exposure  of 
the  body  to  the  excited  Crookes  tube  are  not  due  to  the  X-rays,  but  to 
the  ultra-violet  light  coming  from  the  tube. 

3.  Freund  maintains  that  the  phosphorescent  glow  set  up  by  the 
impact  of  the  cathode  rays  gives  off  a  certain  number  of  ultra-violet 
rays.     This  view  is  endorsed  by  Gilchrist,3  and  Foveau  de  Courmelles.4 
Sir  Oliver  Lodge5  asserts  that  cathode  rays  do  penetrate  the  tube  and 
accompany  the  X-rays. 

4.  By  many  it  is  believed  that  the  X-ray  radiations  are  directly  re- 
sponsible for  the  dermatitis  produced.     Among  the  authorities  that  favor 
this  view  may  be  mentioned  Gassmann,  Schenkel,  Rieder,  Forster,  and 
Kienbock. 

5.  Rollins'  exposed  his  hand  to  a  tube  whose  resistance  was  so  high 

1  Electrical  Review,  November  18,  1896. 

1  Sit/ungsbericht  d.  k.  preuss.  Akad.  d.  Wissenschaften,  Band  viii.,  quoted  by 
Holzknecht. 

'Bulletin,  Johns  Hopkins  Hospital,  February,  1897. 
4Congr.  f.  Neurolog.,  Brussels,  1897. 
5  An  hives  of  the  Rontgen  Ray,  April,  1904. 
•Electrical  Review,  Jan.  5,  1898. 


ACTION  OF  THE  RONTGEN  BAYS.  399 

that  no  current  could  be  forced  through  it  with  the  generator  used ; 
nevertheless,  the  hand  was  burned,  in  spite  of  the  fact  that  no  X-rays 
were  produced.  He  therefore  believed  that  X-ray  burns  could  be  pro- 
duced by  electricity,  but  did  not  show  that  they  could  not  also  be 
produced  by  the  X-rays. 

Those  favoring  the  above  theory  are  Schall,  Leonard,  Bordier, 
Salvador,  Gocht,  and  Apostoli. 

6.  Tesla l  believes  that  burns  are  due  to  the  ozone  generated  on  the 
skin  and  to  a  small  extent  to  nitrous  acid.     He  therefore  interposed  a 
screen  made  of  aluminium  wire,  connected  with  the  ground,  between  the 
tube  and  the  person,  and  no  burn  was  produced.     Before  he  took  this 
precaution  one  of  his  assistants  was  burned. 

Dr.  F.  J.  Clendinnen  has  made  some  experiments  on  the  action  of 
X-rays  on  the  air.  He  found  that  air  which  had  been  irradiated  for  ten 
minutes  gave  a  slightly  acid  reaction  with  phenol-phthalein.  Further 
tests  with  diphenyl-sulphonic  acid  showed  this  to  be  due  to  the  produc- 
tion of  nitric  acid.  He  holds  that  the  healing  and  stimulating  effects  of 
the  X-rays  are  partly  due  to  this  production  of  nitric  and  nitrous  acids. 
This  would  account  for  the  bronzing  and  pigmentation  due  to  X-rays, 
since,  when  nitric  acid  comes  in  contact  with  any  proteid  matter  it  turns 
yellow  owing  to  the  formation  of  xanthoproteic  acid,  which  acid  would 
further  be  darkened  by  the  action  of  the  ammonia  in  the  skin.2 

The  above  theories  are  not  accepted  by  Oudin,  Barthelemy,  and 
Darier. 

7.  Some  individuals  show  a  marked  susceptibility  to  the  action  of 
the  rays.     All  operators  confirm  this  view.      In  some  patients,  X-ray 
burns  have  been  recorded  where  a  single  exposure  of  one  minute  duration 
was  given. 

8.  The  principal  factors  in  faulty  technic  are  : 

(a)  Too  close  proximity  of  the  tube  to  the  part  to  be  irradiated. 
(6)  The  degree  of  vacuum  of  the  tube,   the  soft  tube  being 

most  prone  to  produce  X-ray  dermatitis. 
(c)  Prolonged  or  repeated  exposures. 

The  opinions  held  by  various  observers  as  to  the  etiology  of  X-ray 
burn,  as  detailed  above,  may  not  be  endorsed  to-day  by  some  of  these 
very  scientists.  As  the  study  is  being  more  and  more  unfolded,  new 
theories  are  from  time  to  time  being  advanced  to  account  for  X-ray  der- 
matitis. 

B.  CLASSIFICATION  OF  X-RAY  DERMATITIS. 

It  is  customary  to  divide  X-ray  dermatitis  into  the  acute  and  chronic 
forms. 

1  Electrical  Review,  December  2,  1896. 

*  Intercolonial  Medical  Journal,  October,  1904. 


400  ELECTRO-THERAPEUTICS. 

The  acute  for  tn  may  appear  24  hours  after  the  irradiation,  or  may  not 
manifest  itself  for  two  or  three  months  subsequently  ;  it  is  characterized 
by  the  presence  of  an  erythema.  This  erythema  is  attended  with 
intense  itching,  which  in  a  few  days  may  give  rise  to  vesicle  formation. 
The  erythema  may  be  preceded  by  pigment  formation. 

As  soon  as  the  cutaneous  pigmentation  has  taken  place,  an  effect 
upon  the  hair  may  be  observed.  The  hair  loses  its  natural  lustre,  the 
individual  hairs  become  brittle  and  break  off  close  to  the  hair  follicle 
upoii  the  slighest  friction  or  combing. 

It  should  be  remembered,  when  there  is  an  erythema,  that  this  in 
itself  is  sufficient  to  cause  a  loosening  and  falling  of  the  hair,  without 
injury  to  the  follicle,  hair  papilla,  etc.  Hair  rich  in  pigment  falls  out 
more  readily  than  hair  of  a  sparser  pigment.  I  have  seen  two  <-a>cs 
where  the  hair  had  been  removed  from  the  entire  scalp  by  the  X-rays,  to 
grow  again,  and  more  luxuriantly,  in  a  short  time. 

In  mild  cases  this  is  simply  a  transient  erythema,  lasting  perhaps  a 
few  days,  followed  by  an  exfoliation  of  the  superficial  epidermis.  There 
may  be  a  hypenesthesia  of  the  skin  and  a  mild  burning  sensation,  though 
no  real  pain  is  experienced.  In  the  hairy  portions,  epilation  may  occur 
without  any  active  inflammatory  signs. 

In  cases  of  the  second  degree  there  is  a  formation  of  serous  or  puru- 
lent blebs  following  the  erythema,  and  bearing  a  close  resemblance  to  a 
scald,  but  differing  from  the  latter,  in  that  it  is  decidedly  slower  in  heal- 
ing and  less  acute  in  character. 

In  the  worst  cases,  the  process,  instead  of  disappearing  in  a  few 
weeks,  extends  to  the  deeper  layers  of  the  skin  and  to  the  subcutaneous 
tissue,  resulting  in  the  formation  of  a  leathery  slough,  surrounded  by  a 
brawny  indurated  swelling  with  ill-defined  limits.  The  process  is 
exceedingly  slow  and  obstinate,  and  possesses  a  tendency  to  progress 
It  is  generally  very  painful,  usually  resisting  all  treatment  in  a  most 
remarkable  way. 

The  chronic  form,  found  most  largely  in  the  persons  of  operators 
(Fig.  209),  may  be  regarded  as  a  long-continued  form  of  the  acute  variety, 
and  produced  by  the  constant  irritation  of  the  action  of  the  rays.  Follow- 
ing the  acute  form,  the  nails  become  brittle  and  thinner,  and  show  th*> 
presence  of  linear  striations,  and  later  of  furrows. 

Still  later  onychia  develops,  and  the  nail  is  frequently  shed.  The 
knuckles  become  sensitive  from  a  chapping  of  the  skin,  serum  exudes, 
and  an  itching  sensation  develops,  which  is  often  followed  by  numbness 
and  anaesthesia.  The  skin  becomes  hard  and  leathery,  warty  excrescences 
form,  and  from  the  base  of  these  excrescences  a  clear  serum  issues.  Fre- 
quently these  growths  become  detatched  and  offer  a  raw,  sensitive  sur- 
face. While  the  operator's  hands  are  most  frequently  ''burnt,"  the  phe- 
nomenon may  manifest  itself  on  any  part  of  the  body,  especially  the  fare 
and  the  chest 


FIG.  209.— AUTHOR'S  HAXDS.— Showing  the  result  of  chronic  X-ray  dermatitis. 
(Began  in  1899  and  the  above  photograph  taken  in  1903.) 


ACTION  OF  THE  EONTGEX  KAYS.  401 

Kienbock1  classifies  X-ray  burns  as  follows  : 

Those  of  the  first  degree,  which  appear  from  twelve  to  sixteen  or  more  days  after 
exposure.  The  hair  loosens,  falls  out,  and  leaves  the  skin  smooth,  bald,  and  occa- 
sionally pigmented. 

Those  of  the  second  degree,  where  the  exposure  has  been  more  intense  and 
appears  after  a  briefer  interval  than  in  burns  of  the  first  degree.  There  is  localized 
or  general  swelling.  The  hypenemia,  at  first  light,  later  assumes  a  darker  color. 
There  is  marked  irritation.  These  symptoms  are  followed  by  loss  of  hair,  and  by 
marked  cutaneous  pigmentation  with  subsequent  scaling  ;  the  skin  is  smooth  and  sen- 
sitive, of  a  delicate  hue,  and  devoid  of  hair ;  after  a  time,  however,  the  part  again 
u>sumes  its  normal  aspect,  a  slight  pigmentation  perhaps  remaining. 

Those  of  the  third  degree.  Blisters  and  extensive  exfoliations  are  present,  the 
hair  fails  to  grow  again,  changes  in  the  pigmented  spots  are  permanent,  and  there  is 
atrophy  of  the  cutis  and  papilla-,  with  the  formation  of  painful  cicatrices. 

Th<>-?e  of  the  fourth  degree.  This  is  characterized  by  a  superficial  dry  necrosis. 
After  a  latent  period  of  a  fortnight,  the  skin  is  darkly  discolored,  and  is  the  seat  of 
ulceration,  which  may  be  of  an  indefinite  duration.  The  condition  may  be  painless. 

The  above  methodical  classification  is  purely  arbitrary.  I  have  seen  many  cases 
of  dermatitis  where  the  symptoms  did  not  follow  these  typical  stages. 

C.  THE  LATENT  STAGE  ;  FREQUENCY  AND  SUSCEPTIBILITY  IN  X-EAY 
DERMATITIS. 

E.  A.  Codinan*  shows  that  the  latent  period  in  X-ray  dermatitis 
varies  from  an  interval  of  24  hours  up  to  the  fourth  week  after  the 
irradiation. 

In  9  instances,  signs  or  symptoms  were  noticed  within  24  hours. 
In  6  instances,  signs  or  symptoms  were  noticed  within  2  days. 
In  6  instances,  signs  or  symptoms  were  noticed  within  3  days. 
In  2  instances,  signs  or  symptoms  were  noticed  within  4  days. 
In  5  instances,  signs  or  symptoms  were  noticed  within  5  days. 
In  3  instances,  signs  or  symptoms  were  noticed  within  6  days. 
In  3  instances,  signs  or  symptoms  were  noticed  within  7  days. 
In  4  instances,  signs  or  symptoms  were  noticed  within  8  days. 
In  2  instances,  signs  or  symptoms  were  noticed  within  9  days. 
In  9  instances,  signs  or  symptoms  were  noticed  within  10  days. 
In  8  instances,  signs  or  symptoms  were  noticed  within  10-14  days. 
In  8  instances,  signs  or  symptoms  were  noticed  within  15-21  days. 
In  2  instances,  signs  or  symptoms  were  noticed  within  22-28  days. 
In  3  instances,  signs  or  symptoms  were  noticed  after  the  4th  week. 

From  this  table  we  may  observe  that  it  is  impossible  to  fix  an  exact 
time  when  the  first  symptoms  may  be  expected,  but  the  majority  of  cases 
of  X-ray  dermatitis  make  their  first  appearance  from  the  10th  to  the 
13th  day,  the  cases  occurring  later  having  really  started  previously,  but 
the  symptoms  were  insufficient  to  attract  the  patient's  attention. 

1  "Hautveranderungen    durch   ROntgenbestrahlung  bei    Mensch    und    Thier," 
Wiener  nied.  Presse,  1901,  pp.  874-879. 

2  Philadelphia  Medical  Journal,  March  8,  15,  1902. 


402  ELECTRO-THERAPEUTICS. 

Tii  seven  cases,  two  of  which  came  under  my  care,  a  dermatitis  had 
been  set  up  from  two  to  eight  hours  after  exposure.  There  are  two  cases 
on  record  where  dermatitis  did  not  appear  until  the  thirty-second  day, 
but  I  believe  it  questionable  whether  the  X-rays  were  instrumental  in 
bringing  about  this  belated  condition. 

In  1898  H.  Gocht l  stated  that  in  the  Hamburg-Eppendorf  Hospital, 
out  of  a  total  of  over  2000  exposures,  there  was  only  one  burn. 

Albers-Schonberg,  in  the  same  year,  was  also  of  the  opinion  that  the 
probability  of  a  burn  is  only  very  small.  He,  perhaps  the  most  compe- 
tent X-ray  expert,  says  that,  despite  his  frequent  irradiations  for  diagnos- 
tic purposes,  up  to  that  time  (1898),  he  had  never  seen  a  burn;  and  that 
was  at  a  period  when  exposures  of  twenty  minutes  were  customary,  with 
the  tube  very  close  to  the  body. 

Hofifa 2  says  that  the  occurrence  of  the  burn  is  in  the  proportion  of 
7  to  10,000,  which  small  figure  (0.7  per  cent.)  is  not  obtained  in  the 
statistics  of  even  the  most  harmless  operation. 

It  has  been  said,  that  the  individual  "disposition"  is  an  important 
factor  in  the  relative  frequency  of  X-ray  burns,  and  that  this  disposition 
varies  according  to  the  types  of  the  pigments  of  the  body.  Different 
parts  of  the  body  react  variously  to  the  rays,  the  hairy  regions  being 
especially  sensitive. 

In  an  examination  of  8000  patients  for  diagnostic  purposes,  I  have 
met  with  but  three  mishaps, — one  case  each  of  epilation,  vesication,  and 
ulceration. 

Sjorgen  and  Sederholm s  are  strongly  impressed  with  the  fact  that 
blondes  and  brunettes  react  differently  to  the  action  of  the  rays,  as  shown 
in  the  following : 

A— BLONDES. 

Case  13,  with  21  exposures  ;  reaction  mild. 
Case  4,  with  19  exposures  ;  reaction  mild. 
Case  6,  with  12  exposures  ;  reaction  very  mild. 

B— BRUNETTES. 

Case    1,  with  22  exposures  ;  reaction  strong. 

Case    2,  with  20  exposures  ;  reaction  very  strong. 

Case    5,  with  18  exposures  ;  reaction  present. 

Case    7,  with  16  exposures  ;  reaction  strong. 

Case    7,  with  15  exposures  ;  reaction  ;  second  period,  strong. 

Case    8,  with  15  exposures  ;  reaction  medium. 

Case    9,  with  18  exposures  ;  reaction  intense. 

Case  10,  with  29  exposures  ;  pronounced  swelling. 

Case  11,  with  35  exposures  ;  very  strong  reaction. 

1  American  Electro-Therapeutic  and  X-Ray  Era,  May,  1903. 

'Quoted  by  Scliiirmayer,  Fortschritte  a.  d.  Geb.  d.  Rontgenstr.,  1901,  1902,  v. 
pp.  4K  51. 
3  Ibid. 


ACTIOX  OF  THE  ROXTGEN  RAYS.  403 

Codman1  says:  "Many  assertions  have  been  made  that  the  static 
machine  is  less  liable  to  the  production  of  injuries  by  the  X-rays  than  any 
other  form  of  apparatus,  because  of  the  low  amperage  required ;  this 
statement,  however,  is  not  borne  out  by  the  present  analysis. 

"In  the  cases  in  which  the  kind  of  apparatus  is  recorded,  11  were 
caused  by  static  machines ;  of  these  3  were  severe ;  11  were  caused  by 
Tesla  coils ;  of  these  5  were  severe ;  42  were  caused  by  forms  of  induc- 
tion coils  ;  of  these  18  were  severe. 

"On  the  other  hand,  coils  have  been  far  more  commonly  used  than 
static  machines  or  the  Tesla  apparatus,  probably  in  the  proportion  of  3 
to  1.  In  the  other  cases  in  which  the  apparatus  is  not  spoken  of,  it  is 
probable  that  a  static  machine  would  have  been  used  and  not  mentioned. 
I  believe  that  X-ray  dermatitis  occurs  with  equal  frequency  both  with 
the  coil  and  with  the  static  machine." 

Codmau  further  says  :  "  Unfortunately,  the  quality  of  the  tube  is  not 
recorded  often  enough  to  give  us  effective  data.  Where  it  is  recorded  it 
is  usually  stated  to  be  'soft.'  It  is  the  general  impression  of  skiagraph- 
ers  that  soft  tubes  have  more  therapeutic  influence  than  hard.  It  is 
probable  that  the  distance  from  the  skin  and  the  time  of  exposure  are 
more  important  factors. 

"Maximum  recorded  distance  from  tube  to  skin  at  which  injury  has 
occurred,  was  50  cm.  (statement  of  patient).  Minimum  recorded  distance 
from  tube  to  skin,  1  cm.  Maximum  recorded  time  of  exposure,  20  hours 
(ten  exposures).  Minimum  reported  time  of  exposure,  5  ruin,  (other 
data  not  given).  Considerable  inaccuracy  probably  exists  in  the  ac- 
companying reports  of  times  and  distances.  One  writer  speaks  of  'dis- 
tance from  tube  to  skin;'  another  from  'tube  to  plate,'  or  from  'platinum 
terminal  to  skin,'  still  others  say  the  '  tube  was  so  many  inches  distant,' 
or  perhaps  neglect  the  entire  data." 

Leopold  Freund,2  whose  experience  in  this  field  has  been  enormous, 
says:  "The  dangers  of  Rontgen  therapy  are  not  confined  to  primary 
Rontgen  dermatitis,  which  may  take  months  or  even  years  to  heal,  but  in- 
clude permanent  changes  in  the  integument,  atrophy,  scleroderma,  and 
telangiectases,  which  may  follow  prolonged  and  repeated  irradiations. 
The  most  to  be  dreaded  is  the  primary  Rontgen  dermatitis.  Its  pro- 
tracted duration,  its  painful  nature,  and  the  comparative  uselessness  of 
treatment,  render  these  cases  the  bane  of  both  doctors  and  patients. 

"The  question  arises,  What  is  the  percentage  of  accidental  burns  in 
all  cases  treated  by  Rontgen  therapy!  According  to  Codmau,  up  to  the 
year  1902,  the  total  number  of  recorded  cases  of  severe  burns  due  to  the 
Rontgen  rays  is  172.  He  calculates  that  such  accidents  do  not  exceed  one 

1  The  Philadelphia  Medical  Journal,  March  8  and  15,  1902,  ix.  pp.  4-38. 

2  An  address  delivered  before  the  Wissenschaftliche  Versammlung  des  Wiener 
Medizinischen  Doktorenkolleginms,  February  12,  1906. 


404  ELECTRO-THERAPEUTICS. 

in  5000.     In  the  hospitals  of  Boston  there  were  only  four  cases  of  burns 
in  20,000  radiographic  exposures. 

"Hahn  has  collected  statistics  from  a  number  of  sources  : 

Hahn         treated  303  cases,  and  had  2  Rontgen  ulcers. 
Schiff         treated  505  cases,  and  had  3  Rontgen  ulcers. 
Miiller        treated    47  cases,  and  had  1  Rontgen  ulcer, 
de  Nobele  treated    42  cases,  and  had  1  Rontgen  uk-er. 

"Holzknecht  gives  the  number  of  cases  in  which  reaction  occurred, 
and  not  the  total  number  irradiated.  In  4872  cases  of  reaction,  he  got 
44  cases  of  ulceration. 

"  Many  other  authors  record  cases  of  ulceratiou,  but  do  not  give  the 
total  number  of  cases  treated.  All  agree  that  unforeseen  secondary 
effects  may  include  scarring,  pigmentation,  telangiectases,  atrophy  of  the 
skin  and  nails,  keloid,  and  sclerodermic  changes." 

Between  the  years  1896  and  1904,  Freund  treated  369  cases,  with  a 
total  of  11,808  irradiations.  In  these  369  cases  he  had  3  intense 
reactions. 

D.  PATHOLOGICAL  PHYSIOLOGY. 

Huntington l  quotes  Eudis- Jicinsky  in  that  an  X-ray  dermatitis  con- 
sists of  an  acute,  subacute,  or  chronic  uecrobiosis.  Eudis-Jicinsky,  in  a 
later  article,  states  that  "the  irritation  of  the  peripheral  extremities  of 
the  sensory  nerves  causes  a  paralysis  of  the  vaso- motors  of  the  vascular 
area  affected,  that  spasmodic  contraction  of  the  arterioles  and  capillaries 
follow,  and  the  proper  nutrition  of  the  cells  is  impaired.  With  these 
changes,  which  are  directly  dependent  upon  disturbance  of  the  circula- 
tion, there  are  changes  in  the  parenchyma  cells  of  the  affected  region. 
The  death  of  tissue  follows,  caused  by  permanent  stasis  in  the  blood- 
vessels." 

Lowe*  mentions  the  fact  (first  demonstrated  by  Lord  Kelvin),  that  a 
bar  of  iron,  electrified  and  insulated,  can  be  discharged  or  de-electrified 
by  means  of  the  X-rays.  He  seems  to  be  of  the  opinion  that  an  X-ray 
dermatitis  depends  very  largely  upon  a  similar  action  on  the  trophic 
nerves  of  the  parts  subjected  to  exposure. 

E.  A.  Codman  *  supports  the  theory  that  attributes  the  lesions  to  a 
primary  action  on  the  trophic  nerves  of  the  blood-vessels  and  the  skin. 
He  says,  "the  delay  in  the  appearance  of  the  lesions  after  the  exposure, 
their  progressive  character,  and  their  failure  to  react  to  stimulating 
treatment,  are  the  strongest  reasons  for  this  view."  His  reports  of  the 

1  Annals  of  Surgery,  December,  1901. 

'British  Medical  Journal,  January  18,  1902. 

s  Philadelphia  Medical  Journal,  March  8-15,  1902. 


ACTION  OF  THE  RONTGEX  KAYS.  405 

microscopic  examinations  of  the  excised  tissue  agree  in  that  the  smaller 
arterial  branches  are  occluded,  and  the  appearances  are  not  unlike  those 
of  necrosis  and  inflammation  due  to  other  causes. 

Apostoli1  ascribes  the  cause  of  these  burns  to  an  electrical  stream 
of  high  tension  issuing  from  the  Crookes  tube. 

Oudin,  Barthelemy,  and  Darier 2  believe  that  the  changes  in  the  skin 
are  not  caused  by  the  local  direct  action  of  the  rays  on  the  cells  of  the 
cutis  and  epidermis,  but  that  the  influence  is  transmitted  indirectly 
through  a  tropho-neurotic  action,  having  its  seat  entirely  in  the  central 
nervous  system. 

Destot 3  also  regards  these  changes  as  having  a  tropho-neurotic  origin. 
Kaposi  explains  them  by  a  paresis  of  the  blood-vessels,  whilst  Bordier  is 
of  the  opinion  that  they  originate  in  a  disturbance  of  nutrition. 

Kienbock  believes  in  a  chemical  action  leading  to  disturbances  of 
metabolism,  by  which  the  cells  of  the  tissue  are  led  to  react  in  the  form  of 
a  Eontgen  dermatitis. 

Freund  maintains  that,  through  the  destruction  of  tissue  elements, 
certain  products  arise  whose  absorption  leads  to  constitutional  symp- 
toms. This  would  explain  the  appearance  of  fever  at  the  commencement 
of  severe  Eoutgeu  dermatitis,  before  any  excoriation  or  ulcer  affords  the 
opportunity  for  local  infection. 

L.  Jankau '  believes  that  an  electrolytic  analysis  of  the  cells  takes 
place  from  irradiation,  whereby  the  tissues  are  chemically  affected,  and 
inflammation  is  provoked. 

Gassmann  and  Schenkel5  have  examined  histologically  this  form  of 
dermatitis.  They  found  that  the  tissue  was  not  necrotic  in  the  ordinary 
acceptation  of  the  term,  but  consisted  of  various  characteristic  elements 
easily  stained.  The  chief  of  these  were  bundles  of  collagen  fibres 
of  normal  appearances,  their  nuclei  being  readily  stained  by  the  usual 
methods.  Here  and  there  were  seen  degenerate  forms,  like  those  found 
in  pathologically  altered  tissue,  which  readily  received  nuclear  stains. 
These  were  of  peculiar  aspect,  some  being  drawn  out  into  long  threads, 
others  much  branched,  indented,  or  grouped  in  irregular  clusters.  There 
were  also  a  few  large  lymph -vessels,  and  capillaries  distended  with  blood. 
Elastic  fibres  were  found  in  abundance,  with  here  and  there  collections 
of  crowded  mononuclear  leucocytes  or  a  slight  extravasation  of  blood. 
The  adipose  tissue  was  unaltered. 

Unna6  alone  has  had  an  opportunity  of  examining  microscopically  a 
dermatitis  erythematosa  set  up  by  X-rays  in  the  human  skin.  He  found 

*New  York  Medical  Journal,  October,  1897. 

2  Monatschrift  f.  prakt.  Dermatologie,  1897,  xxv.  p.  417. 

3  Compt.-rend.  Acad.  d.  Sc.,  Paris,  1897,  cxxiv.  pp.  1114-1116. 

4  Internal,  photog.  Monatsschr.  f.  Medicin,  1898,  vol.  v.  pp.  1-7. 

5  Fortschritte,  vol.  xi.  p.  128. 

6Fortschritte  a.  d.  Geb.  d.  Rontgenstrahl.,  B.  xi.,  H.  3,  pp.  118-119. 


406  ELECTRO-THERAPEUTICS. 

the  elastiii  altered,  and  the  bands  of  collagen  swollen,  whence  he  concludes 
that  the  Riintgen  rays  attack  even  the  more  resisting  tissues  of  the  skin. 
He  thereby  explains  their  cumulative  action. 

Sequeira l  speaks  of  a  few  cases  where  the  scar  tissue  that  remained 
contained  many  vascular  places,  designating  them  as  telangiectasrs.  I 
have  seen  three  such  cases,  though  I  could  not  study  the  condition  in 
detail  as  I  would  have  liked. 

In  a  previous  paragraph  it  is  mentioned  that  the  changes  resulting 
from  the  action  of  the  X-rays  are  usually  atrophic  in  form.  On  the 
other  hand,  there  is  a  hypertrophic  tendency  about  the  joints  of  the 
phalanges  and  especially  on  the  dorsum  of  the  hand.  The  condition 
spoken  of  as  hyperkeratosis  is  characterized  by  an  over-development 
of  the  horny  layer  of  the  epidermis.  These  keratotic  areas  are  nothing 
more  than  elevations  that  have  a  broadened  base,  and  which  frequently 
project  above  the  outer  surface  of  the  skin  in  the  form  of  small 
"peaks." 

Usually  the  bases  of  the  keratotic  peaks  are  not  inflamed,  though  I 
have  seen  three  cases  where  the  opposite  condition  was  true.  Cases  are 
reported  where  there  have  been  three  keratoses  distributed  over  the  en- 
tire anterior  surface  of  the  thorax,  the  dorsal  surface  of  hands  and  feet, 
and  over  the  thighs.  Between  the  keratotic  peaks,  the  skin  was  usually 
atrophied  and  pigmented. 

Johnston  l  speaks  of  the  keratotic  peaks  as  "  precancerous  patches," 
he  believing  that  these  points  are  very  prone  to  undergo  epithelioruatous 
changes.  He  reports  a  case  where  a  surgeon  developed  numerous  kera- 
toses on  the  back  of  both  hands,  the  result  of  extensive  use  of  the  rays. 
Two  of  the  larger  peaks  were  excised  and  studied  microscopically  ;  the 
first  revealed  the  cutis  in  a  state  of  subacute  inflammation,  accompanied 
by  an  intense  lymphocytosis  with  a  proliferation  of  fibroblasts. 

E.  DURATION. 

The  duration  of  chronic  dermatitis  is  often  prolonged  over  months 
and  years,  running  an  uninterrupted  course.  Cicatrices  often  remain 
after  the  lesion  has  healed.  In  the  cases  of  X-ray  operators,  chronic 
dermatitis  leaves  the  nails  disfigured  and  deformed,  and  they  never  again 
regain  their  normal  appearance  and  condition.  The  skin  of  the  hand 
remains  tough  and  indurated,  with  the  subsequent  occurrence  of  atrophy. 

The  bones  suffer  no  change,  though  the  knuckles  are  enlarged,  and 
there  is  hypertrophy  of  the  periarticular  tissues  (as  is  evidenced  in  my 
own  hands). 

Movements  of  the  fingers,  in  flexion  and  extension,  are  painful  and 
limited.  Itching,  paraesthesia,  and  anaesthesia  are  present  to  a  greater  or 

1  The  British  Dermatological  Journal,  1902,  xiv. 

'The  Philadelphia  Medical  Journal,  February  1,  1902,  pp.  220-221. 


ACTION  OF  THE  ROXTGEN  BAYS.  407 

lesser  degree ;  this  renders  the  operator  nervous,  irritable,  and  generally 
ill.  Months  and  years  of  rest  and  change  of  occupation  may  fail  to  show 
any  improvement  in  the  condition,  the  skin  remaining  thickened,  dry, 
and  shining;  there  being  present  numerous  red  patches,  with  the  joints 
flexed  and  sensitive. 

When  the  X-rays  were  first  brought  to  the  notice  of  the  medical 
profession,  the  number  of  experimenters  in  this  fascinating  field  were 
numerous.  To-day,  many  of  these  enthusiastic  votaries  have  become  its 
victims,  and  it  is  a  painful  duty  to  inscribe  the  names  of  the  following  as 
among  the  more  prominent  workers  who  have  perished, — martyrs  to  a 
noble  cause :  Mr.  Clarence  Dally,  Thos.  A.  Edison's  assistant,  of  New 
Jersey ;  Mrs.  E.  Fleischman  Aschheim,  of  San  Francisco ;  Dr.  Louis 
A.  "Weigel,  of  Rochester,  New  York  ;  "NV.  C.  Fuchs,  of  Chicago ;  Dr.  A. 
Barry  Blacker,  of  London  ;  M.  A.  Radiquet,  of  Paris.  The  number  of 
operators  that  have  been  disfigured,  maimed,  and  injured  would  form  a 
deplorable  list  of  tremendous  proportions. 

F.  PREVENTIVE  MEASURES  AGAINST  X-RAY  DERMATITIS. 

As  a  prophylactic  measure,  the  patient's  susceptibility  should  be 
carefully  ascertained  by  interrupted  small  doses  of  the  rays.  The 
character  of  the  tube  must  be  considered.  Soft  tubes  produce  a  derma- 
titis more  readily  than  do  hard  tubes,  because  the  latter  afford  less  absorp- 
tion. Another  matter  for  thought,  is  the  distance  of  the  tube  from 
the  patient.  The  more  distant  the  tube,  the  less  will  be  the  danger  of 
burning  the  patient.  In  treating  the  deeper-seated  structures,  the  sur- 
rounding healthy  parts  should  always  be  screened  from  the  rays  by  thin 
sheets  of  lead.  For  filtering  off  the  soft  and  unnecessary  rays,  advantage 
is  taken  of  the  use  of  a  piece  of  leather  or  aluminium  (grounded)  applied 
over  the  part  to  be  irradiated.  As  a  prophylactic  measure  the  treat- 
ment first  employed  by  Dr.  C.  L.  Leonard,  of  Philadelphia,  may  be 
mentioned.  He  employs  the  compound  stearate  of  zinc  powder,  with 
ten  per  cent,  ichthyol,  in  cases  under  treatment,  believing  that  it  not  only 
relieves  the  symptoms  of  acute  dermatitis,  but  also  allows  a  stronger 
dosage  to  be  employed. 

THE  PROTECTION  OF  THE  OPERATOR. 

For  his  own  protection,  the  operator  should  never  use  his  hand  to 
test  the  intensity  of  the  rays.  While  the  patient  is  undergoing  treat- 
ment or  examination,  the  operator  should  be  in  a  communicating  room 
or  behind  a  lead  screen  or  in  a  sentry  box,  where  he  can  observe  the 
fluorescence  of  the  tube  from  a  mirror  suspended  at  a  convenient  angle 
from  the  ceiling.  The  best  place  for  the  operator  to  have  his  lead  pro- 
tection, is  behind  the  anode.  The  absence  of  the  operator  from  the  room 
is  always  advisable  because  its  atmosphere  becomes  ionized  by  the  rays. 


408 


ELECTRO-THERAPEUTICS. 


To  discover  the  presence  or  absence  of  the  rays,  the  operator  may 
employ  an  electroscope  or  photographic  plate,  and  wherever  they  are 
detected  that  region  is  unsafe  for  the  operator.  (Fig.  210.) 

The  Crookes  tube  should  be  covered  with  an  opaque  rubber  shield, 
or,  as  some  recommend,  with  lead  glass  containing  an  interval  of  ordinary 
glass,  for  the  passage  of  the  rays.  Miiller  paints  the  active  hemisphere 


FIG.  210.— Author's  scheme  for  the  operator's  protection. 

with  a  black  opaque  material  and  employs  diaphragms  of  various  sizes. 
The  operator  should  still  further  protect  himself  by  wearing  special 
opaque  rubber  gloves  and  an  apron,  the  latter  to  prevent  injury  to  the 
testicles.  Spectacles  of  lead  glass  are  worn  by  some  to  protect  the  eyes. 
It  is  far  better,  however,  for  the  operator  to  be  out  of  the  room  and  dis- 
pense with  such  protecting  devices. 

G.  TREATMENT  OF  X-RAY  DERMATITIS. 

Treatment  of  the  acute  form  may  be  similar  to  that  employed  in  any 
other  acute  inflammation  of  the  skin. 

Slight  erythema  may  disappear  within  a  few  days,  but  when  the 
irritation  is  excessive  and  accompanied  by  intense  itching,  soothing  rem- 
edies, as,  zinc  oxide  ointment,  compresses  of  ice,  boric  acid,  etc.,  may  be 
employed.  When  the  vesicles  burst  and  the  skin  resembles  the  lesion 
of  pustular  eczema,  a  warm  normal  salt  solution  proved  soothing  and 
efficient  in  one  of  my  patients.  Carbolic  acid,  bichloride  of  mercury, 
and  other  antiseptics  produce  irritation.  I  used  orthoform  on  my  own 
band,  with  the  result  that  a  general  inflammation  resulted. 


ACTIOX  OF  THE  RONTGEN  EAYS.  409 

Too  much  medication  is  dangerous.  Dry  dressings  are  to  be  pre- 
ferred. My  treatment  of  acute  X-ray  dermatitis  consists  in  cleansing  the 
part  with  sterile  water,  covering  it  with  sterile  gauze,  and  in  enjoining 
absolute  rest  of  the  part.  The  general  health  should  be  inquired  into, 
and  the  patient's  diet  should  be  simple  and  uon-stimnlatiug. 

For  the  intense  itching,  immersion  in  hot  water  and  the  employment 
of  dilute  solutions  of  cocaine  are  to  be  recommended.  If  the  operator 
uses  a  dilute  solution  of  carbolic  acid  for  this  purpose,  he  should  remem- 
ber that  its  too  frequent  application  may  increase  the  irritation  and 
even  produce  gangrene.  Xormal  salt  solutions  and  sterile  gauze  dress- 
ings brought  about  rapid  relief  in  an  acute  case  under  my  care  in  the 
Philadelphia  Hospital. 

Treatment  of  the  chronic  form  is  the  same  as  for  the  acute  form,  plus 
other  measures.  The  latter  include  the  employment  of  picric  acid, 
various  ointments  containing  boric  acid,  /inc  oxide,  calcium  salts, 
aristol,  orthoform,  etc.,  with  lanolin,  cold  cream,  vaseline,  etc.,  as  a  base. 
Some  recommend  powders  of  the  above  in  place  of  ointments.  Some 
urge  the  use  of  a  poultice  as  an  analgesic.  When  the  warty  excrescences 
appear,  it  is  good  practice  to  file  them  down  with  a  small  strip  of  sand- 
paper. When  the  knuckles  are  thus  involved,  I  advise  the  use  of  a 
digital  (palmar)  splint,  which,  however,  must  not  be  worn  too  long, 
lest  ankylosis  set  in.  I  also  advise  touching  the  fissures  in  the  skin  with 
a  ten  per  cent,  solution  of  argyrol.  As  salicylic  acid  is  very  stimulating, 
its  use  is  contraindicated.  Continuous  moist  dressings  should  not  be  used, 
as  maceration  of  the  skin  is  sure  to  ensue.  When  the  skin  appears  dry 
and  parched,  nothing  is  so  valuable  as  the  nightly  application  of  lanolin. 

It  is  worthy  of  remark  that  frequently  a  chronic  X-ray  dermatitis, 
apparently  cured,  breaks  out  anew  and  with  increasing  severity.  In 
such  cases  I  employ  an  application  of  twenty  per  cent,  of  zinc  oxide  in 
lanolin  for  several  days.  If  continued  too  long  over-stimulation  will 
occur.  The  internal  administration  of  arsenic  and  the  iodides  is  most 
valuable.  Alcohol  in  all  forms  is  strongly  contraindicated. 

The  following  treatments  are  appended  : 

F.  Engman1  says  that  in  acute  cases  of  the  second  degree  or  milder, 
where  infection  and  ulceration  are  not  complications,  he  has  controlled 
the  intolerable  itching,  assisted  repair,  and  kept  the  surface  aseptic, 
by  the  employment  of  the  following  formula,  which  has  yielded  him 
excellent  results. 

R    Boric  add 12  drams    (46J  grammes). 

Zinc  oxide,  starch,  bismuth  subnitrate,  of  each,     1  ounce 

Olive  oil 1  ounce 

Lime  water 3  ounces 

Rose  water 12  drams 

1  Interstate  Medical  Journal,  July,  1903. 


410  ELECTRO-THERAPEUTICS. 

The  powder  should  be  well  triturated  in  a  mortar  and  the  lanolin 
added.  The  olive  oil  and  lime  water  are  thoroughly  mixed,  and  slowly 
added  to  the  powder  and  lanolin,  keeping  constantly  stirring ;  after 
which  the  rose  water  is  added,  and  the  whole  beaten  up  in  the  mortar 
into  a  light  creamy  paste.  If  there  is  much  pruritus,  1  or  2  per  cent, 
of  carbolic  acid  can  be  added  to  the  mixture.  This  creamy  paste 
should  be  spread  on  several  thicknesses  of  absorbent  gauze,  and  applied 
to  the  surface,  and  a  sheet  of  gutta-percha  tissue  placed  over  it,  to 
prevent  evaporation.  It  is  very  soothing  because  of  the  great  per- 
centage of  water  it  contains,  and  acts  almost  as  a  lotion  without  the 
disagreeable  effects. 

Mr.  H.  Lyle,  Senior  Surgeon  to  the  Liverpool  Hospital,  believes 
X-ray  burns  to  be  reasonably  amenable  to  treatment.  The  method  recom- 
mended is  the  free  application  of  an  ointment,  composed  of  one  dram  of 
lead  oxide,  two  drams  of  carbonate  of  zinc,  one  drain  of  glycerin,  half  a 
dram  of  olive  oil,  to  one  ounce  of  benzoinated  lard. 

Unna !  advises  that  the  hands  be  bathed  from  one-quarter  to  three- 
quarters  of  an  hour  in  warm  water  with  superfatted  soap,  to  be  followed 
by  the  application  of  one  of  the  following  ointments  : 

R    Ung.  Hebraj  rec.  par 25.0  grammes  (386  grains). 

Sol.  calcii  chlorati 10.0  grammes  (154  grains). 

Glycerini 5.0  grammes  (77  grains). 

Adipia  lanse 10.0  grammes  (154  grains). 

or 

R   Ung.  Hebrae  rec.  par 35.0  grammes  (540  grains). 

Acidi  ealicylici 2.5  grammes  (39  grains). 

Sap.  kalini 2.5  grammes  (39  grains). 

Vaselini 10.0  grammes  (154  grains). 

Dr.  Nogier  *  recommends  for  the  burning,  itching,  and  pain  in  acute 
dermatitis : 

R   Water 3  ounces          (90  grammes). 

Gelose 20  grains       (1.25  grammes). 

Glycerin,  oxide  of  zinc,  of  each 3  drams          (12  grammes). 

Norman  Walker*  uses  the  following  : 

R   Prepared  chalk 3  drams  (12  grains). 

Olive  oil 2  drams    (8  grains). 

Prepared  lard 1  dram     (4  grains). 

1  Fortschritte  auf  dem  Gebiete  der  Rontgenstrahlen,  vol.  viii.,  No.  2. 
'Archives  dY'lectricit^  m£dicale,  Sept.  25,  1906. 
*  British  Medical  Journal,  1901,  ii.  p.  852. 


ACTION  OF  THE  RONTGEX  RAYS.  411 

Dr.  J.  Hall  Edwards1  advises  the  use  of  the  following  : 

R    Sulphate  of  zinc 5  grains  (0.32  grammes). 

Tincture  of  lavender 60  minims  (4  c.c.). 

Glycerin 60  minims  (4  c.c.). 

Water 1  ounce  (30  c.c.). 

Ft.  lotio. 

He  likewise  advises  the  application  of  olive  oil  several  times  daily  to 
the  hands,  to  be  followed  with  hot  water  and  superfatted  soap. 

Since  the  above  was  written,  I  have  been  using  EichhofTs  superfatted 
resorcin  soap,  but  the  results  are  unsatisfactory,  as  the  soap  removes 
the  epithelial  layer  and  renders  the  irritated  remaining  layers  most 
tender.  Oudin  recommends  a  peroxide  of  hydrogen  dressing  in  cases  of 
erythema  and  excoriations. 

M.  "VV.  Brinkmann  advocates  Bier's  method  of  inducing  passive 
hyperaemia, — i.  e.,  by  constrictiou  of  the  venous  circulation  above  the 
diseased  area. 

Professor  Lassar,  of  Berlin,  applied  radium  over  the  ulcerated  spots 
of  my  hands,  but  I  could  derive  no  benefit  from  the  treatment,  as  I  could 
not  continue  it.  But  I  am  doubtful  as  to  its  ultimate  efficacy. 

In  passing,  it  is  interesting  to  note  that  in  the  treatment  of  X-ray 
burns  advantage  has  been  taken  of  the  caloric  power  of  the  red  rays  and 
of  the  absence  in  these  rays  of  chemical  properties.  The  experiments  of 
Finsen,  Schenk,  and  Graber  have  abundantly  proved  that  white  light  is  a 
stimulating  agent  of  considerable  power,  and  Bar  and  Boulle  *  describe  at 
length,  the  case  of  a  pregnant  woman  treated  at  the  Infirmary  of  Saint 
Lazare,  who  suffered  from  bleuorrhagia,  accompanied  by  abdominal  pains. 
She  had  been  pregnant  about  three  months,  when  the  rays  were  applied 
to  the  abdomen  in  the  hope  of  producing  a  blister  and  thus  allaying  her 
intense  pains.  An  ulcer  formed  which  baffled  all  treatment.  Two  months 
after  delivering  two  healthy  infants  the  woman  was  placed  in  a  sunny 
corridor,  and  each  day  the  rays  of  the  sun  were  sent  through  red  glass  and 
allowed  to  fall  on  the  abdomen.  Over  the  ulcerated  area  was  placed  a 
transparent  sheet  of  celluloid.  At  night  the  ulcerations  were  covered 
with  an  inert  powder.  Gradually  the  crusts  produced  by  the  X-rays 
sloughed  off,  and,  fifty  days  after  this  treatment  was  begun,  the  healing 
was  hastened  by  cauterization  with  silver  nitrate. 

Freund  and  Huntington  advise  excision  of  the  ulcer  in  obstinate  cases 
and  that  the  operation  of  skin  grafting  be  resorted  to.  I  concur  in  this 
advice.  Apostoli  and  Oudiu  recommend  the  effluve  from  a  static  ma- 
chine and  a  resonator  respectively.  I  do  not  believe  that,  at  the  present 
day,  there  is  any  agent  known  for  the  cure  of  X-ray  dermatitis.  All  of 
the  proposed  measures  are  merely  palliative. 

1  The  Archives  of  the  Rontgen  Ray,  October,  1903. 

2  Bulletin  de  la  Socit-te  d'Obstetrique  de  Paris,  1901,  vol.  iv.  pp.  251-266. 


4li>  ELECTKO-THEEAPEUTICS. 

II.  Remote  and  Indirect  Action  of  the  Rays. 

Peculiar  sensations  attending  and  sometimes  subsequent  to  irradia- 
tion are  often  complained  of  by  the  patient.  These  include  nervous  dis- 
turbances,— /.  e.  dizziness,  somnolence,  and  tinnitus.  The  circulatory 
disturbances  are  increase  in  the  pulse  rate,  palpitation,  and  cardialgia. 
Digestive  disturbances  manifest  themselves  in  nausea,  vomiting,  and  occa- 
sionally in  diarrhoea.  These  symptoms  may  occur  in  both  the  patient  and 
the  operator.  It  is  my  own  belief  that  some  of  these  symptoms  may  be 
manifestations  of  psychical  influences. 

CKMTO-URINARY  SYSTEM  (STERILITY). 

That  the  Rontgen  rays  are  capable  of  inducing  at  least  temporary 
sterility  should  never  be  lost  sight  of.  Long  ago  the  possibility  of  this 
unfortunate  occurrence  was  emphasized  by  Albers-Schonberg.1 

The  experiments  of  Halberstaedter 2  disclosed  the  fact  that  marked 
macroscopic  and  microscopic  changes  occurred  in  the  ovaries  of  rabbits 
exposed  to  the  rays.  "  The  histological  change  most  in  evidence  was  the 
complete  disappearance  of  the  Graafian  follicles,  in  about  fifteen  days. 
Whether  this  loss  is  permanent  and  whether  or  not  regeneration  can  take 
place,  has  not  yet  been  determined.  It  was  also  found  that  the  ovaries 
seemed  more  sensitive  to  the  effects  of  the  rays  than  the  outer  skin  of  the 
abdomen,  and,  when  compared  with  control  experiments  in  male  rabbits, 
developed  degenerative  changes  in  shorter  time  and  with  fewer  expos- 
ures. How  far  these  observations  in  animals  apply  to  human  beings  can- 
not be  definitely  stated,  nor  is  it  known  how  permanent  the  effect  may 
be.  Of  course  the  question  of  individual  susceptibility  must  also  be 
taken  into  account,  but  since  the  wearing  of  an  apron  impervious  to  the 
rays,  or  the  encasing  of  the  focus  tube  so  as  to  prevent  the  escape  of  all 
rays  except  those  intended  for  a  particular  region  under  treatment,  and 
to  avoid  applying  the  rays  to  'danger  zones,'  would  seem  to  obviate  all 
danger  in  this  direction." 

Albers-Schonberg 3  called  attention  to  the  fact  that  in  male  rabbits 
and  guinea-pigs,  in  which  the  abdomen  was  exposed  to  the  action  of  the 
X-rays,  azoospermia  was  gradually  developed.  Frieben4  found  that  this 
was  due  to  the  disappearance  of  the  epithelium  in  the  seminal  tubules, 
which  resulted  in  an  atrophy  of  the  testes. 

Before  the  January  (1905)  meeting  of  the  section  for  Geuito-Urinary 
diM-ases  of  the  New  York  Academy  of  Medicine,  the  statement  was  made 
by  F.  Tilden  Brown  and  Alfred  T.  Osgood  that  men,  by  their  presence  in 

1  Munch,  med.  Wochen.,  1903,  i.  43. 

*  Berliner  klin.  Wochensch.,  January  16,  1905. 

3  American  Journal  of  Surgery,  April,  1905. 

4  Miinch.  med.  Woch.,  1903,  No.  Hi.  p.  2295. 


ACTION  OF  THE  KOXTGEX  RAYS.  413 

an  X-ray  atmosphere  incidental  to  radiography,  may,  after  a  period  of 
time,  be  rendered  sterile. 

This  statement  was  based  upon  discovering  that  ten  X  ray  workers, 
who  had  consulted  them,  were  the  subjects  of  total  azoospermia,  although 
none  of  them  had  suffered  from  any  venereal  disease  or  traumatisui  in- 
volving the  genital  tract,  none  of  them  presented  physical  signs  of  abnor- 
mality of  these  organs,  and  none  was  conscious  of  or  gave  a  history  of 
functional  derangement. 

Since  that  time  the  number  of  cases  has  increased  and  there  now  are 
records  of  eighteen  cases  in  whom  total  azoospermia  or  oligo-necrosper- 
mia  has  been  demonstrated.  All  of  those  examined  who  have  done  ex- 
tensive X-ray  work  for  a  period  of  more  than  three  years  show  no  sper- 
matozoa in  their  seminal  fluid,  while  a  few  of  the  men  who  have  been 
engaged  in  the  work  for  a  shorter  time  and  have  exercised  care  in  avoid- 
ing direct  exposure  to  the  active  tube  show  varying  states  of  oligo- 
necrospermia.  Several  cases  have  been  examined  whose  exposures  have 
been  infrequent  and  short  (once  or  twice  a  week,  for  from  five  to  fifteen 
minutes),  whose  seminal  fluid  presents  normal  characteristics,  with 
abundant  actively  motile  spermatozoa. 

These  men  are  in  robust  health,  and  from  22  to  40  years  of  age. 
Twelve  of  them  have  operated  X-ray  tubes  for  one-half  to  four  hours 
at  least  three  times  a  week,  for  the  greater  part  of  each  year  during  the 
past  two  to  six  years.  Six  of  them  are  the  subjects  of  more  or  less 
severe  X-ray  dermatitis  of  the  hands. 

This  sterility  has  been  produced  without  the  slightest  subjective  or 
objective  sign,  illustrating  its  insidious  development.  In  no  case  has  even 
a  transient  erythema  of  the  scrotum  been  noted,  and  in  no  case  has  there 
been  evidence  of  deterioration  of  sexual  activity.  One-half  of  these 
men  are  married,  and  no  one  among  them  has  had  a  child  since  he 
undertook  this  work. 

Philipp a  reported  the  exposure  of  the  testes  of  two  men  who  recog- 
nized the  danger  of  producing  sterility.  One  was  a  tuberculous  subject, 
and  he  was  exposed  for  30  days  to  the  raj^s,  duration  of  each  seance  10  to 
l.~»  minutes.  At  the  end  of  this  time,  the  semen  was  apparently  normal, 
and  the  spermatozoa  normal.  Later  a  resection  of  the  vas  deferens  of 
each  side  was  performed,  and  six  months  after  no  spermatozoa  were  found 
in  fluid  withdrawn  from  the  epididyniis.  This  demonstrated  merely  a 
marked  resistance  of  these  organs,  in  this  case  at  least,  to  the  injurious 
action  of  the  rays. 

The  second  case  was  treated  for  pruritus  ani.  Total  time  of  expo- 
sure 195  minutes.  The  patient  then  disappeared.  After  several  months 
he  had  a  slight  recurrence  of  pruritus.  Seven  months  later,  examination 

1  American  Journal  of  Surgery,  April,  1905. 

2  Fortschritte  auf  dem  Gebiete  der  Rontgenstrahlen,  1904,  B<1.  viii.,  Heft  2,  p.  114. 


414  ELECTRO-THERAPEUTICS. 

of  seminal  fluid  showed  complete  azoospermia.  Only  one  examination 
seems  to  have  been  made. 

Bergonie"  and  Tribondeau1  have  extended  their  experiments  on 
the  seminiferous  tubes  to  the  action  of  the  rays  on  the  spermatozoa 
themselves.  The  result  was  entirely  negative.2 

In  conclusion,  let  me  remark,  while  many  operators  say  that  X-ray 
workers  after  a  time  are  permanently  sterile,  I  am  personally  acquainted 
with  six  well-known  active  specialists  in  this  field  who  during  the  past 
year  became  fathers  of  healthy  children. 

1  Arch,  d' 6lectricit6  Medicale,  November,  1906. 

*  For  a  comprehensive  study  of  this  subject,  the  reader  is  referred  to  the  follow- 
ing papers  :  Heineke — Mitteilung  aus  den  Grenzgebieten  der  Medizin  und  Chirurgie, 
1905,  Bd.  xiv.,  Hefte  1  und  2,  pp.  21-94  ;  Munch,  med.  Wochenschrift,  1903,  No. 
xlviii.,  p.  2090,  and  1904,  No.  xviii.,  p.  785  ;  Freund,  Elements  of  General  Radio- 
therapy ;  Senn,  New  York  Medical  Record,  August  22,  1903  ;  Krause,  Fortschritte  auf 
dem  Gebiete  der  Rontgenstrahlen,  1905,  Bd.  viii.,  Heft  3,  p.  209  ;  Halberstaedter,  Ber- 
liner klin.  Wochenschrift,  January  16, 1905  ;  Selin,  Fortschritte  auf  dem  Gebiete  der 
Rontgenstrahlen,  1903,  Bd.  vii.,  Heft  6,  p.  322. 


CHAPTER  III 

CHANGES  INDUCED  IN  VABIOUS  DISEASED  TISSUES  BY  THE 

EONTGEN  BAYS. 

THE  following  are  the  changes  noted  in  psoriasis  by  X-ray  expos- 
ures. We  abridge  the  reports  of  Scholtz.1  The  diseased  area  was  ex- 
posed to  the  rays  from  May  31  to  June  6,  five  times,  of  ten  minutes  dura- 
tion each,  at  40  cm.  distance.  June  8,  the  scales  had  completely  fallen 
off  and  the  affected  area  was  completely  smooth  and  colored  with  dark 
brown  pigment.  The  healthy  skin  in  the  vicinity  was  also  slightly 
colored.  At  this  time  a  piece  of  the  cutis  was  excised  containing  both 
the  healthy  and  the  diseased  tissue. 

"Microscopically,  the  typical  changes  occasioned  by  the  disease  had 
almost  completely  vanished.  Only  the  horny  layer  and  the  stratum 
gramilosuin  were  still  somewhat  thickened,  and  there  was  some  infiltra- 
tion of  the  papillae  and  also  around  the  subpapillary  vessels  of  the  corium. 
The  epithelial  cells  themselves  again  showed  the  usual  changes.  The 
healthy  as  well  as  the  diseased  tissues  were  peculiarly  pigmented.  In 
one  place  in  the  corium,  especially  in  the  papillae,  were  cells,  some  long, 
some  stellate,  with  irregular  nuclei,  whose  protoplasm  was  abundantly 
filled  with  round,  large,  yellowish-brown  particles  of  pigment.  More- 
over, the  cells  of  the  rete,  especially  in  the  deeper  layers,  contained  in 
their  protoplasm  fine  particles  of  the  same  color ;  while  a  fine  network  of 
particles  of  pigment,  lying  close  to  each  other,  appeared  interwoven 
around  these  cells." 

Scholtz  also  studied  the  changes  taking  place  in  lupus.  A  rather 
deep  area  of  lupus  was  on  the  breast,  which  was  deeply  infiltrated, 
thickly  set  with  tubercles,  and  covered  with  a  thin  crust.  X-ray  treat- 
ment. February  8  to  March  7,  at  intervals,  in  all  ten  exposures,  at  35  cm. 
distance.  After  a  few  weeks  a  severe  dermatitis  of  the  exposed  surface 
appeared,  with  subsequent  superficial  necrosis.  Excision  March  17. 

"  Microscopic  examination  showed  the  epithelium  in  a  degenerated 
homogeneous  condition.  The  cutis,  especially  in  the  lupus  area,  was 
infiltrated  with  round  cells  and  pus  cells.  The  form  and  typical  structure 
of  the  tubercles  had  disappeared,  and  were  to  a  certain  extent  absorbed. 
In  their  place  were  collections  of  numerous  cells,  single  and  multiple ; 
nucleated  with  swollen  washed-out  protoplasm  ;  and  among  them  mono- 
nuclear  and  especially  polymorphonuclear  leucocytes  in  great  numbers. 
The  giant  cells  contained  an  unusually  large  number  of  nuclei,  and 

1  Arch.  f.  Derm.  u.  Syph.,  1902,  lix.  p.  241. 

415 


416  ELECTRO-THERAPEUTICS. 

iiit-asured  100  to  200  microns  in  diameter.  Most  of  them  no  longer 
show  regular  outlines,  but,  instead,  a  pale,  irregular  mass  of  multi- 
nucleated  protoplasm.  The  altered  epithelioid  cells,  which  are  often 
poly  nuclear,  showed  the  same  appearance.'' 

Grouven l  gives  a  report  of  his  studies  of  lupus  of  the  cheek  treated 
by  the  rays.  He  studied  sections  of  the  diseased  tissue  which  had  been 
continuously  treated  by  the  rays  for  a  period  of  ten  weeks.  He  noted  a 
very  large  production  of  connective  tissue,  some  of  the  fibres  running 
through  the  tubercles  themselves.  In  brief,  Grouven  speaks  of  the  heal- 
ing of  lupus  tissue  as  an  active  hypersemia  giving  rise  to  diapedesis 
of  the  leucocytes,  first  observed  at  the  periphery  of  the  tuberculous 
masses,  gradually  extending  into  the  interior  of  the  tubercles.  There  is 
a  conversion  into  spindle-cells,  resulting  in  the  complete  production  of 
new  connective  tissue;  i.  e.,  the  cells  of  the  tubercles  undergo  fatty 
degeneration,  absorption,  and  finally  are  wholly  replaced  by  connective 
tissue  newly  formed. 

Scholtz*  speaks  of  the  results  of  his  investigations  with  leprosj-  of 
the  nodular  type,  after  having  been  treated  by  the  rays.  He  exposed  a 
leprous  area  until  sufficient  hyperaemia  was  produced.  He  believes  that 
"  some  time  after  the  disappearance  of  this  reaction  the  part  of  the  nodule 
which  had  been  treated  seemed  to  be  a  little  sunken,  but  no  further 
change  appeared.  Five  weeks  later  the  nodule  was  excised.  Microscop- 
ically, the  leprous  infiltration  was  slightly  reduced.  The  numerous 
bacilli  seemed  to  show  more  granulations  than  the  unexposed  region,  but 
were  well  stained  and  undimiuished  in  number,  the  action  of  the  rays 
having  no  apparent  influence  upon  them."  He3  has  also  studied  cases  of 
cancer  treated  by  the  X-rays,  and  found  that  in  one  case  he  was  able  to 
obtain  sections  in  the  stage  of  commencing  reaction,  and  also  after  the 
formation  of  a  superficial  necrosis.  Under  the  influence  of  the  rays  the 
microscopic  examination  showed  that  the  cancer  cells  degenerate  and  are 
destroyed.  However,  the  degenerative  processes  are  recognizable,  espe- 
cially in  the  deeper  carciuomatous  points,  only  after  a  relatively  more 
intense  action  of  the  rays,  and  the  appearances  were  very  often  difficult 
to  distinguish  from  the  normal  retrogressive  processes. 

Freund  4  states  that  in  lupus  and  epithelioma  the  improvement 
observed  is  due  to  cellular  infiltration  and  proliferation,  and  to  the  influ- 
ence of  the  rays  in  promoting  the  formation  of  connective  tissue  and 
cicatrices.  In  his  opinion  the  X-rays  possess  no  bactericidal  qualities. 

Chas.  Lester  Leonard 5  is  of  the  opinion  that  the  X-rays  have  both 

'Fortschr.  a.  d.  Gebiete  d.  Rontgenstrahlen,  1002,  Bd.  v.  p.  186. 

'Arch,  f.  Derm.  u.  Syph.,  1902,  lix.  p.  241. 

8  Ibid. 

4  Lancet,  August  2,  1902. 

'American  Medicine,  October  4,  1902. 


CHANGES  INDUCED  IN  DISEASED  TISSUES.  417 

stimulating  and  alterative  effects  on  normal  tissue.  There  may  be 
caused  a  retrograde  metamorphosis,  on  tissues  of  low  vitality,  ending 
in  fatty  degeneration.  He  adheres  in  general  to  the  tropho -neurotic 
theory. 

The  lesions  in  Shaud's l  case  were  recurring  superficial  abscesses  of  18 
months'  standing,  the  pus  containing  the  staphylococcus  pyogenes  aureus. 
Improvement  began  under  X-ray  treatment,  a  relapse  occurring  when 
treatment  was  discontinued.  Irradiation  was  again  begun  and  continued 
until  a  permanent  cure  resulted. 

Kinehart,2  after  stating  that  he  gets  no  results  from  X-ray  treat- 
ment unless  inflammatory  action  is  induced,  says:  "It  then  remains 
to  be  decided  whether  the  inflammation  causes  the  death  of  the 
cancer  and  tuberculous  deposits,  or  whether  the  effect  is  produced  by 
the  light  itself.  My  own  experience  is,  that  it  is  the  light.  Simple 
inflammation  has  often  been  caused  by  caustics,  in  and  around  these 
sores  of  lupus  and  epitheliouia,  without  producing  the  death  of  the 
process.  A  light  sufficiently  strong  to  produce  an  inflammation  of  the 
healthy  cells  of  the  part  treated  is  of  sufficient  strength  to  destroy  cells 
of  lower  vitality,  as  cancer  cells  are  known  to  be.  Whether  the  effect 
upon  the  skin  is  produced  by  the  ultra-violet  rays  remains  to  be  proven. 
That  the  low-vacuum  tube  produces  more  effect  upon  the  skin  than 
the  high-vacuum  tube,  might  help  to  substantiate  the  statement  that  the 
effect  is  from  ultra-violet  rays,  as  they  are  given  off  more  freely  from  the 
low-vacuum  tube." 

Hallopeau  and  Gadaud3  call  attention  to  the  sclerogenic  action  of 
the  X-ray,  to  which  they  properly  attribute  the  ungual  dystrophies  and 
the  vascular  dilatation  produced  thereby. 

Herzog4  treated  transplanted  sarcomas  in  two  rats.  The  skin  over 
the  tumor  became  necrotic  in  each  case.  In  one,  the  tumor  changed 
to  a  cyst  filled  with  a  perfectly  clear  fluid  material,  and  after  the  fifth 
exposure  the  whole  tumor  came  away,  leaving  a  clean  surface. 

Walker5  has  studied  sections  of  rodent  ulcer  healing  under 
treatment  by  the  X-rays,  and  describes  the  new  growth  as  undergoing 
fibro-myxomatous  degeneration. 

Blackmar6  concludes  that  the  X-rays  cause  a  breaking  down  of 
malignant  and  non-malignant  growths,  the  disintegrated  material  being 
absorbed.  He  considers  the  waste  products  from  a  rapidly  disintegrating 
cancer  exceedingly  dangerous  when  thrown  into  the  general  system, 
unless  the  patient  is  in  vigorous  health. 

1  Australasian  Med.  Gazette,  May  20,  1902. 

2  American  Journal  of  the  Medical  Sciences,  July,  1902. 

3  La  Presse  Med.,  July  16,  1902. 

4  Journal  of  Medical  Research,  June,  1902. 
5 British  Med.  Jour.,  May  10,  1902. 

'American  Electrotherapy  and  X-Ray  Era,  May,  1902. 


418  ELECTEO-THEEAPEUTICS. 

Morton  *  believes  that  the  effect  of  the  X-rays  in  the  cure  of  disease 
is  due  to  a  primary  chemical  reaction,  affecting  in  turn  the  metabolic  pro- 
cesses. He  claims  that  under  proper  conditions  the  X-rays  build  up  tis- 
sue, in  proof  of  which  he  cites  the  case  of  a  young  woman  suffering  from 
enlarged  axillary  glands.  In  six  weeks,  the  neck,  shoulders,  chest,  and 
breast  of  that  side  had  developed  so  markedly  that  the  patient  afterward 
desired  the  opposite  side  treated  in  order  to  restore  symmetry. 

Beck  *  states  that  an  adeno-carcinoma,  subjected  to  the  X-ray  treat- 
ment, showed  beginning  colloid  degeneration,  changes  of  the  same  nature 
being  observed  in  the  epithelium  of  the  skin  covering  the  tumor.  Speci- 
mens of  the  affected  skin  showed  thickening  of  the  intima  of  the  small 
blood-vessels ;  fibrous  tissue  in  reticular  arrangement  being  deposited. 
The  same  observer  elsewhere  states  that  he  regards  as  most  important,  the 
nutritive  changes  in  the  walls  of  blood-vessels  and  the  results  incident  to 
such  changes. 

Loeb,s  after  seven  exposures  of  ten  minutes  each  during  eleven  days, 
transplanted  sarcoma  in  a  rat  and  found  mitoses  in  the  cells.  The  tumor 
continued  to  grow,  and  pieces  from  it  were  successfully  transplanted  into 
other  rats.  Degenerative  changes  were  present  in  the  centre  of  the  tu- 
mor, but  Loeb  believes  that  these  changes  occur  in  many  tumors  without 
exposure  to  the  rays. 

A.  G.  Ellis,4  in  regard  to  tissue  changes,  occasioned  by  the  X-rays, 
reports  upon  the  findings  in  four  cases,  which  were  carefully  examined. 
He  observed  necrosis  of  cells  and  trabeculae  of  a  varying  degree.  There 
was  also  marked  fatty  degeneration .  In  three  cases  there  was  increase  of 
elastic  tissue  before  and  after  exposure.  In  one  case  there  were  fewer 
areas  of  lymphocytic  infiltration  after  exposure,  and  about  equal  numbers 
before  and  after  in  others.  A  tendency  to  occlusion  of  the  vessels,  by 
deposits  on  their  inner  surfaces,  was  marked  in  some  cases.  Entire  absence 
practically  of  infiltration  of  polymorphonuclear  leucocytes  was  noted. 
These  findings,  he  remarks,  hardly  warrant  conclusions,  but  a  few 
thoughts  suggest  themselves.  The  blood-vessel  changes,  on  which  Beck 
and  others  lay  stress,  seem  hardly  to  account  for  the  accompanying 
tissue  necrosis,  though  endarteritis  is  probably  induced  by  the  X-rays. 
He  thinks  the  possibility  is  suggested  of  their  being  similar  lesions  from 
the  same  influence  instead  of  standing  in  relation  of  cause  and  effect. 
The  presence  of  immense  numbers  of  cocci  and  bacilli  in  the  tissues  in 
one  case  after  twenty  exposures,  would  argue  against  the  bactericidal 
power  of  the  rays.  It  should  be  said,  however,  that  the  pathogeuicity  of 
these  organisms  was  not  proven. 

1  Medical  Record,  May  24,  1902. 
*  New  York  Med.  Journal,  May  24,  1902. 
s  Journal  of  Medical  Research,  June,  1902. 

4  A.  G.  Ellis,  in  American  Journal  of  the  Medical  Sciences,  January,  1903,  from 
which  many  of  the  above  statements  have  been  taken. 


CHANGES  INDUCED  IN  DISEASED  TISSUES.  419 

Yose  and  Howe,1  from  a  study  of  the  effects  of  X-rays  on  cancer, 
believe  that,  "  Cutaneous  cancer  treated  by  the  X-rays  undergoes  degene- 
ration not  peculiar  to  this  form  of  treatment  or  distinguishable  histologi- 
cally  from  degeneration  from  other  causes.  The  vascular  changes  are 
limited  to  an  endarteritis  ;  new  formation  of  blood-vessels  occur,  if  heal- 
ing takes  place,  as  in  the  process  of  repair  elsewhere  ;  there  is  an  increase 
of  elastic  tissue.  Taken  as  a  whole,  the  clinical  cases  show  that  the  only 
cure  of  cancer  by  the  X-ray  is  by  destruction  and  exfoliation.  This  at 
once  limits  its  value  to  superficial  cases.  This  destructive  process  is  a 
slow  one,  and  acts  very  superficially  .'' 

Journal  of  Medical  Research,  Boston,  January,  1905. 


CHAPTER  IV 
TECHNIC  OF  EONTGEN  RAY  THERAPY. 

THE  production  of  a  dermatitis,  the  result  of  the  use  of  the  X-rays 
as  a  diagnostic  measure,  early  suggested  the  possible  value  of  the  new 
agent  for  therapeutic  purposes.  Treatment  with  the  X-rays  depends 
largely  upon  the  character  of  the  lesion.  Thus  the  same  method  of  treat- 
ment would  be  of  no  avail  if  applied  indiscriminately  to  the  malignant 
and  benign,  to  the  superficial  and  to  the  deeper  tissues,  etc.  Effective 
technic  in  treatment  is  dependent  not  only  upon  a  good  understanding  of 
how  to  use  effective  apparatus  accurately,  but  also  upon  the  experience 
and  ability  of  the  operator  to  apply,  to  each  individual  case,  the  quality 
and  dose  that  that  particular  case  demands. 

In  observing  the  progress  of  disease,  so  far  as  a  cure  is  concerned, 
and  also  for  comparative  study  of  several  diseases,  a  life-sized  photograph 
of  the  affected  area  should  be  taken  before  the  actual  treatment  is  com- 
menced. The  plate  employed  should  be  isochromatic  in  type,  in  order 
that  the  color  value  of  the  tissues  may  be  recorded  as  exactly  as  possible. 
To  be  accurate  all  these  photographs  should  be  taken  in  precisely  the 
same  manner.  The  prints  made  from  the  resulting  negatives  should  be 
of  equal  density. 

"When  an  open  wound  is  to  be  treated,  care  must  be  exercised  not  to 
infect  it ;  if  it  is  well  protected  by  a  sterile  dressing,  this  should  not  be 
removed,  unless  ointments  are  smeared  thereon  which  might  offer  ob- 
struction to  the  rays,  such  as  zinc  oxide,  boric  acid,  bismuth,  iodoform. 
etc.  I  would  urge  that  all  lesions  be  covered  with  several  layers  of  gauze 
while  treatment  is  in  progress. 

I.  Apparatus  and  Method  of  Treatment. 

The  apparatus  necessary  for  intelligent  and  effective  treatment  is 
practically  the  same  as  that  employed  for  skiagraphic  purposes.  The 
current  for  exciting  a  tube  is  generated  by  a  static  machine,  an  induction 
coil  of  the  Ruhmkorff  type,  or  a  Tesla  high-frequency  apparatus.  Some 
operators  prefer  the  static  machine,  believing  that  it  does  not  produce  a 
dermatitis,  but  this  has  been  proved  a  fallacy.  Regarding  the  size  of  the 
coil  for  therapeutic  purposes,  one  that  is  of  seven  or  eight  inch  (18  to  20 
cm.)  spark  producing  power  will  suffice. 

When  using  a  coil  for  therapeutic  purposes,  the  frequency  of  pro- 
longed exposures,  often  required,  is  liable  to  injure  the  insulation  of  the 
coil.  It  is  considered  advisable  to  switch  off  the  current  and  allow  the 
coil  and  the  tube  to  cool  every  ten  or  fifteen  minutes,  during  prolonged 
420 


TECHtfIC  OF  EONTGEX  RAY  THERAPY. 


421 


W&B.MFG.CO.N.Y 


FIG.  211.— PIFFAED  TREATMENT:  TUBE.— The  whole  tube  is  made  of  lead  glass,  except  at  the  lower 
opening,  to  permit  the  passage  of  the  rays  for  therapeutic  purposes.  This  is  a  protective  measure  for 
the  operator,  and  also  limits  the  area  irradiated. 


FIG.  212. — THE  BI-CATHODE  TUBE  OF  KOCH  OF  DRESDEN. — Koch  asserts  that  where  much  in- 
verse current  must  be  overcome,  this  tube  acts  both  as  an  X-ray  and  a  ventril  tube.  He  believes  that, 
the  anode  being  of  a  heavy  design,  a  large  quantity  of  current  may  be  employed  with  a  shortened 
exposure.  (Kny-Scheerer  Co.) 


H«T    VH 

: ' -— -j; .-  SH^S 


THE:  KNY-SCHEERER  co.  M.Y. 


FIG.  213. — THE  KNY-PCHEEKER  TTBE.— The  anode  is  placed  into  the  tubular  extension,  the  latter 
being  encased  by  a  cylinder  of  lead-flux  glass.  A  set  of  two  specula  of  lead  glass  further  serve  to 
localize  the  X-rays. 


422 


ELECTKO-THEEAPEUTICS. 


treatment;  but,  the  current  being  of  small  amperage,  the  injury  to  the 
coil  at  most  would  be  slight.  The  mechanical  or  the  liquid  interrupter 
may  be  employed,  but  the  mechanical,  being  the  cleaner  and  easy  of  manip- 
ulation, is  commonly  used.  The  electrolytic  interrupter  has  met  with 
little  favor,  as  the  enormous  current  transmitted  to  the  primary  is  totally 
unnecessary,  and  is  detrimental  to  the  life  of  the  tube  and  the  coil. 

CKOOKES  TUBE. 

The  tubes  employed  for  therapeutic  purposes  (Figs.  211,  212,  213, 
and  214)  are  practically  similar,  in  degree  of  vacuum,  to  those  employed 
for  diagnostic  purposes.  They  are  self-regulating,  or  those  in  which  the 
vacuum  can  be  altered  by  automatic  appliances.  Tubes  are  also  classified 
according  to  their  degree  of  vacuum,  as  "soft,"  "medium,"  and  "hard." 
The  rays  coming  from  a  tube  of  low  vacuum  produce  an  early  and  rapid 


Fio.  214.— Dr.  J.  Ronsenthal's  tube  for  therapeusis,  as  employed  by  him  in  the  hospitals  of  Munich. 

tissue  change.  When  a  softer  tube  is  employed  more  tissue  change 
results,  because  under  such  conditions  the  rays  are  considerably  less 
penetrating  and  more  readily  absorbed  by  the  tissues,  than  with  a  hard 
tube.  This  is  the  accepted  view  of  most  X-ray  operators.  When  the 
suspected  lesion  is  deep-seated,  as  in  cases  of  carcinoma  of  the  uterus, 
stomach,  or  abdomen,  a  "medium"  tube  should  be  used.  The  connec- 
tion of  the  Crookes  tube  with  the  oscilloscope  is  explained  at  Fig.  215. 

PROTECTION  OF  HEALTHY  PARTS. 

Prior  to  the  application  of  the  rays  (as  in  cases  of  superficial 
ulcers,  epithelioma,  etc.)  the  surrounding  normal  tissue  should  be  pro- 
tected against  the  influence  of  the  rays.  This  may  be  accomplished  by 
shielding  the  surrounding  integument  by  leaden  sheets,  &  of  an  inch 
(1  mm.)  in  thickness,  covered  with  adhesive  plaster,  and  grounded,  in 
which  an  aperture  has  been  cut,  to  permit  the  passage  of  the  rays. 
The  aperture  should  be  of  the  same  size  as  the  superficial  lesion.  This 


TECHXIC  OF  BONTGEN  BAY  THEEAPY. 


423 


precaution,  however,  does  not  apply  to  lesions  that  are  deep-seated,  the 
risk  of  setting  up  an  integumentary  inflammation  weighing  but  little  in 
comparison  with  the  gravity  of  the  condition. 

An  ingenious  device  is  the  protective  tube  shield,  which  conforms  to 


FIG.  215. — CONNECTION  OF  THE  TUBE  AND  VILLARD  VALVE  WITH  THE  OSCILLOSCOPE. — Piffard,  of 
New  York,  uses  the  oscilloscope  as  an  index  of  the  inverse  current.  When  the  inverse  current  is  exces- 
sive, a  violet  glow  will  appear  on  both  terminals  of  the  oscilloscope ;  if  the  current  is  unidirectional  the 
glow  will  be  manifest  only  on  one  terminal  of  the  oscilloscope.  The  oscilloscope  is  in  reality  a  Geissler 
bulb. 


the  size  and  shape  of  the  Crookes  tube,  and  is  provided  with  different 
sized  cylinders,  or  localizers,  allowing  either  a  large  or  small  surface  to  be 
acted  upon  by  the  rays. 


424  ELECTRO-THERAPEUTICS. 

POSITION. 

The  position  of  the  tube  is  of  little  importance,  except  that  the 
anodal  field  must  face  the  lesion.  The  satisfactory  application  of  the  rays 
to  such  conditions  as  carcinoma  of  the  cervix  uteri,  diseases  of  the  oral 
cavity,  the  larynx,  stomach,  and  rectum  is  a  matter  of  much  difficulty.  If 
the  tube  is  placed  within  a  cavity,  or  in  such  a  position  as  to  send  the 
rays  directly  to  the  seat  of  the  lesion,  better  results  are  to  be  expected 
than  if  the  rays  need  penetrate  some  intervening  tissue.  For  this  reason 
tubes  of  special  shape  have  been  designed  by  Caldwell  of  New  York, 
and  Cossar  of  London,  for  the  express  purpose  of  treating  diseases  of 
the  rectum,  vagina,  and  oral  cavity.  The  tube  devised  by  Caldwell 
has  a  long  cylindrical  projection  which  fits  into  a  metallic  protector. 
The  latter  has  an  opening  which  corresponds  to  the  area  undergo- 
ing treatment.  The  Cossar  tube  is  constructed  of  lead  glass  com- 
paratively opaque  to  the  rays,  except  at  the  end  of  the  projection, 
which  is  made  of  ordinary  glass,  and  permits  the  rays  to  reach  the 
diseased  area  only. 

DISTANCE  OF  THE  TUBE. 

The  distance  of  the  tube  from  the  part  depends  upon  the  quality  of 
the  tube,  upon  the  size  of  the  area  to  be  treated,  and  whether  a  rapid 
reaction  is  desired  or  not.  It  is  measured  from  the  target  of  the  tube  to 
the  exposed  surface.  The  nearer  the  tube,  the  more  intense  the  action. 
Theoretically,  some  claim  that  the  distance  of  the  tube  from  the  part 
should  be  directly  as  the  height  of  its  vacuum  and  inversely  as  the 
distance  of  the  part  to  be  affected  is  from  the  surface.  Some  operators 
prefer  a  short  distance  with  short  or  less  frequent  exposures.  This  I 
believe  to  be  a  matter  of  personal  experience,  and  can  only  be  deter- 
mined by  a  most  careful  study  of  each  and  every  case  seeking  treat- 
ment. The  anode  of  a  hard  tube  should  usually  be  placed  from 
twelve  to  fifteen  inches  (30  to  38  cm.)  from  the  surface,  and  a  soft  tube 
from  six  to  eight  inches  (15  to  20  cm.).  On  the  other  hand,  the  tube 
should  l>e  placed  nearer  to  the  body,  the  farther  the  diseased  part  is  from 
the  surface. 

Dr.  "William  S.  Xewcomet l  has  devised  a  frame  covered  with  lead, 
containing  openings  in  three  of  its  sides,  and  employed  by  him  for  X-ray 
therapeusis.  The  sizes  of  these  windows  may  be  modified  by  the  insertion 
of  few  or  many  lead  diaphragms.  The  Crookes  tube  is  placed  within  the 
frame,  with  the  active  hemisphere  directed  towards  the  openings.  As 
three  patients  can  always  be  treated  simultaneously,  much  time  is  sav«-d 
by  this  device.  But  patients  must  be  selected  that  demand  the  same 
quality  of  the  rays,  as  exemplified  in  large  hospitals. 

1  American  Medicine,  March  5, 1904. 


TECHNIC  OF  RONTGEN  BAY  THERAPY.  425 

Dr.  H.  P.  "Wells,  of  St.  Louis,  has  very  kindly  sent  me  the  following 
description  of  his  ingenious  method,  for  the  multiple  connection  of 
Crookes  tubes  in  series,  as  a  means  of  economy  of  time  and  current. 

''It  has  been  found  practical,"  he  writes,  "to  connect  in  series  more 
than  one  Crookes  tube  to  be  operated  from  a  single  coil  or  static  machine, 
and  thereby  increase  the  usefulness  of  such  equipment  to  meet  the  needs 
of  those  doing  much  clinical  work  and  with  whom  the  question  of  time 
and  expense  are  matters  of  consideration. 

"The  tubes  are  connected  so  as  to  maintain  the  proper  direction  of 
flow  of  current  in  both  of  them,  that  is,  the  anode-terminal  of  one  tube 
is  connected  to  the  cathode-terminal  of  the  second,  etc. 

"It  is  hardly  practical  to  use  more  than  two  tubes  on  the  average 
coil  or  static  machine,  as  the  resistance  and  consequent  strain  on  the 
machine  increases  by  arithmetical  progression  with  the  number  of  tubes 
in  the  circuit. 

"It  is  possible  to  maintain  each  tube  at  any  desired  resistance  by 
adjusting  the  shunt  spark-gap  on  the  regulating  device  of  the  tube,  each 
tube  regulating  itself  independently  of  its  fellow. 

"The  only  apparent  difficulty  in  the  way  of  the  multiple  connection 
of  the  tubes,  is  the  strain  thrown  on  the  interrupter,  especially  of  the 
mercury  jet  type.  I  believe  that  a  perfected  form  of  mechanical  inter- 
rupter will  prove  least  troublesome  and  give  the  best  results  under  the 
higher  resistance  in  the  secondary. 

"Economy  of  current  is  effected,  because  we  use  the  latter  in  the 
second  tube,  which  ordinarily  is  dissipated  in  the  form  of  heat  in  the 
rheostat  when  only  one  tube  is  used." 

This  method  has  also  been  employed  in  the  London  Hospital,  where 
they  also  run  a  series  of  coils  from  the  same  interrupter  and  on  the  same 
primary  current. 

THE  DURATION  OF  EACH  EXPOSURE. 

This  depends  on  whether  a  coil  or  static  machine  is  used,  and  upon 
the  patient's  susceptibility  and  the  character  of  the  case.  Operators  differ 
in  the  length  of  time  of  exposure.  Some  resort  to  frequent  but  short 
exposures  with  ascending  doses,  others  employ  longer  but  less  frequent 
exposures.  If  the  integument  remains  normal,  the  stances  are  length- 
ened, twenty  minutes  being  the  maximum.  All  other  things  being  equal, 
the  usual  time  of  exposure  with  a  coil  is  less  than  with  the  static 
machine. 

FREQUENCY  OF  THE  EXPOSURE. 

This  depends  upon  the  character  of  the  lesion,  the  rapidity  of  action 
desired,  the  length  of  each  exposure,  the  susceptibility  of  the  patient, 
and  on  the  distance  of  the  tube.  At  the  very  beginning  of  treatment, 


426  ELECTEO-THEEAPEUTICS. 

it  is  advisable  to  expose  the  patient  two  or  three  times  a  week  for  the 
first  two  weeks,  and  then  to  discontinue  treatment  for  a  similar  period, 
watching  in  the  interval  for  the  development  of  any  untoward  symptoms. 
Some  prefer  to  give  a  treatment  every  other  day,  asserting  that  this  pro- 
cedure is  productive  of  the  best  results.  This  necessitates  very  close 
watching  of  the  patient's  susceptibility,  but  if  caution  is  observed  not  to 
over-expose  the  seat  of  disease,  then  the  applications  may  be  brought 
more  closely  together  for  almost  an  indefinite  length  of  time.  Periods 
of  rest  for  tissue  restoration,  other  than  that  just  mentioned,  should 
never  be  attempted,  as  under  this  plan  all  is  lost  that  may  have  been 
gained  through  the  treatment  of  the  previous  days  or  weeks. 

FILTERS. 

Concerning  the  law  of  the  absorption  of  the  Eontgen  rays,  "\Valters  * 
finds  that,  after  these  rays  pass  through  silver,  palladium,  cadmium, 
zinc,  and  antimony,  they  are  soft  instead  of  hard.  In  other  words, 
these  metals  absorb  the  hard  rays,  while  aluminium,  copper,  and  the 
metals  at  the  extremes  of  the  scale  of  atomic  weights  absorb  the  soft  rays. 
The  second  layer  of  any  specified  substance  absorbs  less  rays  than  the 
first.  This  principle,  he  believes,  can  be  applied  practically  in  inter- 
posing a  substance  similar  to  the  skin  in  the  treatment  of  deep-seated 
growths  without  sacrificing  the  skin. 

Drs.  G.  E.  Pfahler  and  J.  F.  Schamberg*  conducted  a  series  of 
experiments  upon  rabbits,  in  which  use  was  made  of  silver,  leather,  and 
aluminium,  for  the  purpose  of  establishing  their  values  as  filters.  They 
found  leather  of  decided  advantage  for  filtering  out  the  soft,  medium,  and 
hard  rays.  They  were  impressed  with  the  fact  that  the  susceptibility  to 
the  rays  varied  in  different  animals,  which  doubtless  is  also  true  of  man. 
It  has  been  my  practice  for  some  time  past  to  employ  aluminium  and 
leather  filters,  but  I  decidedly  prefer  the  former. 

THE  DOSAGE. 

By  "  dosage  "  is  meant  the  quantity  and  quality  of  the  Eontgen  rays 
used  during  each  exposure.  This  depends  upon  whether  the  condition  is 
superficial  or  deep,  malignant  or  benign.  Some  believe  in  exposing  the 
part  until  tanning  or  bronzing  occurs,  but  in  dark-skinned  individuals, 
in  negroes,  and  in  mucous  membranes  no  tanning  is  observed ;  hence  in 
these  instances  this  sign  cannot  be  depended  upon.  I  have  noticed  that 
itching  often  indicates  the  beginning  of  a  reaction  within  the  tissue. 
If  the  treatment  is  continued  after  the  development  of  these  signs, 
erythema,  vesication,  or  dermatitis  may  develop,  whereupon  the 

!  Fortechritte  auf  dem  Gebiete  der  Rontgenstrahlen,  Berlin,  April  13,  1905. 
*  Journal  of  the  American  Medical  Association,  September  15,  1906,  p.  888. 


TECHNIC  OF  RONTGEN  RAY  THERAPY.  427 

operator  should  cease  treatment.     These  effects  do  not  necessarily  mean 
carelessness  on  his  part  and  may  occur  in  most  skilful  hands. 

Although  the  clinical  manifestations  are  a  guide  in  determining  the 
amount  of  reaction  obtained,  yet  they  do  not  indicate  the  exact  amount 
of  the  X-rays  used.  The  possible  methods  of  determining  the  "  dosage" 
are  fully  detailed  and  discussed  in  a  special  section. 

II.    Methods  of  Measuring  X-Ray  Dosage. 

Since  Rontgen' s  discovery,  scientists  have  lacked  a  practical  and 
oxact  unit  of  X-ray  dosage.  The  establishment  of  a  standard  unit  is 
difficult,  because  of  the  idiosyncrasy  of  the  patient,  and  because  no  one 
can  make  any  positive  statement  as  to  the  number  of  treatments  that 
any  one  case  may  demand,  the  personal  equation  entering  so  largely  into 
the  consideration.  We  cannot  deduce  the  amount  of  physiological  and 
biological  action  of  the  rays  on  the  tissues  by  the  measurement  of  their 
chemical  and  physical  properties.  The  question  arises  :  What  standard 
shall  we  adopt,  so  that  the  unit  may  be  accurate,  practical,  and  precise  ! 
Recently  the  Rontgen  Ray  Society  of  London  appointed  a  committee  for 
the  purpose  of  formulating  a  standard  unit  for  the  measurement  of  all 
radiations ;  they  arrived  at  no  definite  conclusion  and  asked  for  the 
earnest  cooperation  of  American  scientists.1 

A.  MEASUREMENT  OF  ELECTRIC  CURRENTS. 

The  Current  going  to  the  Primary  Coil. — The  voltage  and  amperage  of 
a  current  that  goes  to  a  coil  depends  upon  the  variety  of  the  interrupter 
and  the  construction  of  the  primary  coil.  The  secondary  or  induced 
current  depends  upon  the  variety  of  the  current  or  winding  of  the  coil, 
because  the  same  coil  and  interrupter  may  give  a  different  quality  of  the 
rays,  depending  upon  the  make  and  the  vacuum  of  the  tube.  Wertheim 
Salomouson's  experiments  show  that  electric  energy  is  absorbed  in  the  rhe- 
ostat and  in  the  interrupters.  "Wehnelt  considers  that  30  to  80  per  cent,  of 
the  energy  derived  from  a  battery  is  absorbed  by  the  electrolytic  break. 
Salomouson's  wattmeter  showed  that  61.2  and  65.4  per  cent,  of  current 
was  lost.  Since  this  percentage  of  lost  energy  evidently  varies  under 
different  conditions  of  operation,  it  follows  that  the  induced  secondary 
current  is  not  proportional  to  the  primary  current  when  an  electrolytic 
interrupter  is  used. 

Milliamperaye  of  the  Secondary  Induced  Current. — The  milliampere- 
meter  was  first  advocated  by  D' Arson val,  who  used  it  with  a  Yillard 
tube,  and  proved  that  the  production  of  X-rays  is  proportionate  to  the 
intensity  of  the  current,  and  has  shown  photographs  in  support  of  this 

1  At  a  meeting  of  the  American  Rontgen  Ray  Society  held  at  Niagara  Falls,  August, 
1906,  I  urged  the  appointment  of  a  committee  to  confer  with  a  like  committee  of  the 
Rontgen  Ray  Society  of  London,  which  was  agreed  to. 


428  ELECTRO-THERAPEUTICS. 

assertion.  The  milliampererneter  measures  the  current  passing  through 
a  tube  ;  but  does  not  tell  us  how  much  energy  is  expended  in  the 
production  of  the  rays. 

Salomonson  asserts  that  X-ray  production  is  a  function  of  watts  ex- 
pended in  the  tube  rather  than  of  the  current  traversing  it.  If  his  theory 
is  correct,  and  I  believe  that  it  is,  then  we  should  know  the  amount 
of  energy  or  watts  expended  in  heating  the  anode. 

The  niilliamperemeter  measures  the  resistance  of  the  tube.  There 
are  degrees  of  vacuum  where  no  X-rays  are  produced,  yet  the  mil  Hani - 
peremeter  indicates  a  passing  current.  The  resistance  of  a  tube  often 
depends  upon  the  shape  and  angle  of  the  anode  (platinum),  upon  the 
surface  of  the  cathode,  and  upon  the  focal  distance  of  the  cathode.  A 
valve  tube  makes  the  current  unidirectional,  as  shown  by  the  ossilograph  ; 
the  latter  also  shows  absence  of  constant  movement  in  the  needle,  whilst 
the  milliamperemeter  shows  the  slight  changes  in  the  vacuum  by  the  de- 
flection of  the  needle.  It  should  never  be  forgotten  that  the  reading  of 
the  milliamperemeter  is  not  necessarily  an  absolute  index  of  the  amount 
of  X-ray  production  in  the  tube.  Thus,  we  read  the  milliamperage  and 
we  know  that  the  current  is  passing  from  the  secondary  into  the  tube ; 
but  how  much  of  the  current  going  through  the  tube  is  expended  in  the 
production  of  the  X-rays?  So  much  depends  upon  the  make,  shape,  size, 
etc.,  of  the  tube  and  upon  the  relation  existing  between  the  cathode  and 
anode  that  the  answer  is  difficult,  if  not  impossible.  However,  Salo- 
monson '  described  and  exhibited  a  new  instrument  for  measuring  the 
energy  of  a  variable  current  of  high  potential.  The  milliamperemeter 
usually  used  for  measuring  the  current  in  the  secondary  circuit  indi- 
cates the  mean  current,  whereas  what  we  really  require  is  the  mean 
square  value,  and  with  an  oscillating  current  these  two  values  are  not 
proportional. 

The  dilatometer  devised  by  Professor  Saloniouson  measures  the 
energy  expended  in  the  secondary  circuit  directly.  It  consists  of  a 
paraffin  oil  thermometer,  which  is  heated  by  the  current  passing  through 
a  slate  resistance.  Slate  has  a  high  and  fairly  constant  electric  resistance. 
The  heating  effect  of  even  a  small  current  is  therefore  readity  apprecia- 
ble. The  heat  is  communicated  to  the  surrounding  paraffin,  and  the  con- 
sequent expansion  in  the  paraffin  is  shown  in  a  capillary  tube  attached  to 
the  vessel.  The  rise  of  the  meniscus  in  this  tube  will  therefore  be  a 
measure  of  the  total  energy  expended  in  the  circuit  during  the  time  the 
current  has  passed  through  the  resistance.  The  dilatometer  sums  up  the 
values  of  the  energy  for  each  instant  since  the  current  was  started ;  its 
readings  will  therefore  be  proportional  to  the  mean  square  of  the  current, 
and  the  rise  of  the  meniscus  per  unit  time  will  give  the  mean  square 
intensity  of  the  current.  The  dilatometers  are  standardized  by  means  of 

1  Archives  of  the  Rontgen  Ray,  April,  1906. 


TECHX1C  OF  ROXTGEX  RAY  THERAPY.  429 

an  electro-dynamometer  and  a  stop-watch,  a  small  steady  current  being 
passed  through  the  two  instruments. 

Experiments  with  these  instruments  showed  that  the  efficiency  of  a 
Ruhmkorff  coil  is  the  same  for  all  intensities  of  current  in  the  primary, 
that  the  rexixtance  in  the  secondary  circuit  remains  unaltered. 

/netrr. — Measuring  the  length  of  the  spark-gap  (parallel)  on 
the  secondary  coil  or  induced  current  was  the  earliest  method  employed. 
The  length  indicates  the  internal  resistance  of  a  tube  to  the  passage  of 
the  current ;  the  longer  the  spark-gap  the  higher  will  be  the  vacuum. 
But  it  is  a  fact  that  the  variation  in  the  supply  of  current  in  the  primary 
coil  or  interrupter  will  change  the  length  of  the  spark-gap,  with  the  same 
tube  in  circuit.  The  pointed  rods  of  the  electrodes,  the  composition  of 
the  rods,  the  atmospheric  conditions,  such  as  moisture,  etc.,  the  construc- 
tion of  the  coil,  interrupter  etc.,  the  source  of  current  and  also  the 
amount  of  the  current,  will  alter  the  length  of  the  spark-gap.  Two 
different  tubes  with  the  same  current  and  same  spark-gap  may  give 
different  degrees  of  radiation,  because  the  size  of  the  electrodes  may  be 
different  and  different  metal  may  be  used,  etc.  Beclere,  of  Paris,  em- 
ploys a  graduated  rod  capable  of  sliding  to  and  fro.  On  this  scaled 
bar  he  observes  the  number  of  inches  or  centimeters.  This  is  a 
convenient  form  of  measurement,  and  every  coil  is  thus  supplied  and 
is  universally  employed.  This  method  is  often  misleading,  as  I  have 
seen  a  tube  with  3-  or  4- inch  (7.5-  or  10-cni.)  spark-gap,  where  the 
rays  were  far  less  penetrating  and  in  some  instances  cathodic  rays  were 
produced. 

The  data  given  by  the  spinterineter  holds  good  only  for  the  special 
apparatus  that  the  operator  employs  and  not  necessarily  for  other  forms 
of  this  apparatus. 

B.  THE  PENETRATION  METHOD. 

By  this  means  we  measure  the  penetrative  property  or  quality  of  the 
rays  directly  outside  of  the  tube. 

The  Itadiochromometer  of  Benoist  (Fig.  216). — M.  L.  Benoist  devised 
this  instrument,  which  is  based  upon  the  principle  that  different  metals 
possess  different  degrees  of  transparency  as  regards  their  penetration  by 
the  X-rays.  A  silver  disk  in  the  centre  of  this  device  having  a  thickness 
of  0.11  of  a  millimeter,  is  used  as  standard.  Around  this  disk  are  placed 
layers  of  aluminium,  beginning  with  one  layer  and  up  to  12,  like  the  dial 
of  a  clock.  These  12  sectors  are  designated  by  lead  numbers,  so  that  one 
can  recognize  them  by  their  position  without  seeing  the  number.  This 
apparatus  can  be  used  either  with  the  fluoroscope  or  on  a  photographic 
plate.  One  of  the  sectors  will  match  the  tint  of  the  central  disk.  A 
lead  diaphragm  is  provided  for  bringing  one  sector  into  view,  and  the  dia- 
phragm is  then  rotated  until  the  tint  of  the  sector  corresponds  to  the  tint 


430 


ELECTRO-THERAPEUTICS. 


of  the  centre.  M.  Benoist1  improved  upon  this  apparatus.  His  device 
resembles  a  telescopic  arrangement,  whereby  the  numbers  and  the  tints  on 
the  screen  appear  enlarged ;  it  is  also  furnished  with  a  glass  to  protect 
the  operator  while  testing  the  rays.  By  rotating  the  lead  diaphragm  one 
can  examine  each  sector  successively.  Dr.  Geo.  Pfahler 2  places  a  mirror 


FIG.  216. — Benoist's  radiochromometer. 


at  an  angle  of  45  degrees,  utilizing  the  principles  of  the  reflecting  fluoro- 
scope  (Figs.  217,  218),  thus  preventing  the  rays  being  directly  projected 
upon  the  face  or  hand,  and  in  this  way  minimizing  the  danger  of  burns. 
Dr.  Lacaille*  has  devised  an  apparatus  which  is  simply  a  Benoist  radio- 
chromometer associated  with  a  lunette,  of  similar  disposition  to  that  used 

1  Archives  d'electricite"  medicale,  April,  1906. 
1  Archives  of  Physiological  Therapy,  June,  1906. 

3  Bulletin  Officiel  de  la  Socie'te'  Fran^aise  d'Electrothe"rapie  et  de  Radiologie, 
July  and  August,  1905. 


Ku;.  217.—  The  improved  benoist  radiochromometer. 


FIG.  218.— The  same,  with  its  parts  connected. 


FIG.  219.— The  skiameter. 


TECHNIC  OF  RONTGEX  RAY  THERAPY. 


431 


by  Brandt  in  his  posometer.  Such  a  lunette  is  formed  of  two  parts  :  a  box 
6  x  8  x  10  centimeters  and  an  eye-piece  placed  close  to  it  at  an  angle  of  45°. 
The  box  in  his  apparatus  presents  two  interesting  points :  (1),  on  the 
bottom  and  placed  at  an  angle  of  45°  is  a  mirror  in  which,  when  looking 
through  the  tube,  one  can  see  the  inferior  surface  of  the  upper  wall  of  the 
box ;  on  said  inferior  surface  is  affixed  a  pasteboard  disk  covered  with 
barium  platino-cyanide ;  (2),  on  the  superior  surface  of  the  same  upper 
wall,  exactly  above  the  platino-cyanide  disk,  is  the  radiochromometer,  the 
shade  of  which  is  projected  by  the  X-rays  on  the  little  screen,  and  reflected 
in  the  mirror.  With  such  a  disposition  the  operator  is  not  directly 
exposed  to  X-rays. 

All  radiochromometers  give  only  penetration  power,  but  we  know 
that  there  is  a  great  difference  between  the  penetration  and  fluores- 
cence, and  also  between  photographic  (chemical)  and  physiological  (ther- 
apeutic) effects. 

Skiamcters  and  Penetrometers. — The  principle  of  these  devices  consists 
in  the  use  of  an  obstacle  to  the  passage  of  the  rays.     (Fig.  219.)     Many 
different  metals  have  been  used  to  determine  the  penetrative  power  of  the 
rays,  but  as  with  Benoist's  de- 
vice these  forms  of  apparatus 
do  not  indicate  the  intensity 
of  the  rays.     Two    different 
tubes    which  have   the  same 
penetrative  power  may  differ 
in  their  chemical  and  physio- 
logical effects. 

Crypto-radwmeter  of  Weh- 
nelt. — This  apparatus  (Fig. 
220)  consists  of  a  fluoroscope 
with  a  sliding  or  telescopic 
arrangement  and  provided 
with  a  sheet  of  lead  to  pro- 
tect the  hand  of  the  operator 
and  a  single  "V "-shaped 
piece  of  metal  which  grad- 
ually increases  in  thickness. 

It  is  claimed  by  Wehnelt  that  his  apparatus  is  more  accurate  and  allows 
of  a  wide  range  of  comparison  because  of  the  wedge-shaped  character  of 
the  piece  of  aluminium. 


FIG.  220.— Crypto-radiometer  of  Wehnelt. 


C.  THE  PHYSICO-CHEMICAL  METHOD. 

Because  of  its  accuracy  and  precision,  I  believe  that  physico-chemical 
measurement  more  nearly  approaches  the  ideal  than  the  other  procedures 
in  vogue.  This  method  has  been  ably  illustrated  by  Holzknecht.  He 


432  ELECTKO-THERAPEUT1CS. 

based  his  theories  and  constructed  his  apparatus  upon  the  principle  that 
certain  salts  suffer  a  change  of  color  when  exposed  to  the  cathode  rays. 
Other  substances,  when  heated  and  irradiated,  undergo  a  change  of  color, 
as  the  chloride  of  lithium,  which  becomes  a  greenish-yellow,  and  carbon- 
ate of  potassium,  which  changes  to  a  heliotrope.  On  exposure  to  the  air, 
or  at  a  high  temperature,  the  colors  of  these  salts  are  seen  to  disappear. 
He  also  proved  that  X-rays  and  Becquerel  rays  possess  this  property,  and 
that  they  are  all  transformed  into  ultra- violet  rays  at  the  point  of  impact 
with  the  surface. 

Chromoradiometer  of  Holzknecht. — Guido  Holzknecht,  of  Vienna,  pre- 
sented this  device  for  the  consideration  of  the  profession  in  1902.  Holz- 
knecht's  studies  on  this  subject  led  him  to  fuse  certain  salts  and  to 
expose  them  to  the  action  of  the  rays.  He  employs  a  small  capsule  con- 
taining the  reagent  covered  with  celluloid.  This  reagent,  which  is  color- 
less and  whose  composition  has  heretofore  been  kept  a  secret,  has  been 
analyzed  by  a  French  chemist,  Mr.  Lind,1  and  M.  Bordier  describes  it  as 
follows :  "  The  reagent  consists  of  99.77  per  cent,  potassium  sulphate,  the 
remainder  being  potassium  sulphite  or  hyposulphite,  or  possibly  potassium 
tri-,  tetra-,  or  penta-thionate.  The  mixed  mass  is  impregnated  and  held 
together  with  copal  varnish.  This  capsule  (which  is  placed  over  the  cuta- 
neous area  to  be  treated)  has  a  dirty-yellow  color  due  to  the  copal  varnish, 
and  under  the  influence  of  the  X-rays  the  color  changes  to  a  greenish  tint, 
gradually  becoming  deeper  as  the  quantity  of  the  rays  is  increased.  After, 
or  often  during,  the  irradiation  this  capsule  is  brought  near  to  a  standard- 
ized scale  which  is  graduated  in  Holzknecht  units,  from  1  H.  to  24  H.,  the 
color  scale  being  graduated  from  a  greenish-yellow  to  a  deep  green,  which 
serves  as  a  standard  of  comparison  for  j  udging  the  color  of  the  capsule 
after  irradiation.  The  unit  is  indicated  by  H.  This  method  has  certain 
disadvantages  :  The  treatment  is  interrupted  in  order  to  compare  the  color 
of  a  reagent  with  that  of  the  scale,  and  this-is  repeated  until  a  tint  is  ob- 
tained which  corresponds  to  the  precise  dose  required.  As  more  than  one 
sitting  may  often  be  necessary  (in  the  interval  between  the  two  exposures), 
this  reagent  must  be  kept  in  darkness.  This  graduated  scale  holding 
the  numbered  capsule  is  kept  in  a  light-proof  box.  Although  this  method 
would  seem  very  correct  in  theory,  nevertheless,  in  practice  we  meet  with 
many  difficulties.  The  standard  scale  suffers  changes  in  color,  or  it  may 
fade  in  the  course  of  a  year.  Subsequent  to  exposure  the  capsule  gets 
darker  and  must  be  compared  immediately.  The  comparison  of  the  cap- 
sule with  the  scale  is  very  difficult.  Different  individuals  and  different 
parts  of  the  body  exhibit  different  degrees  of  susceptibility,  and  the 
various  diseases  display  individual  peculiarities  to  the  action  of  the  rays. 

Radiometer  of  Sabouraud  and  Noire. — In  1904  Drs.  Sabouraud  and 
Noire"  introduced  a  method  largely  employed  in  France.  It  consists  of  a 

1  Archives  of  the  Rontgen  Ray,  June,  1906,  p.  6. 


TECHXIO  OF  ROXTGEX  RAY  THERAPY.  433 

small  disk  of  paper  over  which  is  spread  a  layer  of  platino-bariuin  cya- 
nide ;  this  salt  assumes  a  brown  color  under  the  action  of  the  X-rays.  M. 
Yillard  pointed  out  that  under  the  influence  of  increasing  doses  of  the  rays, 
plantino-cyanide  passed  from  a  bright  green  to  brown,  and  at  the  same 
time  the  fluorescence  gradually  decreased.  Upon  a  two-page  leaflet  is  the 
standard-color  pastille,  marked  "  A  "  (which  is  an  unchanged  green  color), 
and  another  one  marked  UB,"  which  is  brown,  and  indicates  the  maximum 
dose  the  skin  can  tolerate  without  producing  dermatitis,  and  causing 
only  epilation.  The  comparison  should  be  done  in  a  dimly  lighted  room, 
because,  if  the  pastilles  are  exposed  for  too  long  a  period  to  the  light,  they 
regain  their  original  green  color.  The  pastille  should  be  placed  in  a  pas- 
tille-carrier, 8  cm.  from  the  anode,  and  midway  between  the  part  under 
treatment  and  the  anode.  The  standard  color  pastille  UB"  corresponds 
to  a  dose  of  10  X,  or  5  H  in  Holzknecht  units.  Sabouraud  himself  ad- 
mitted that  the  test,  however,  is  less  sensitive  than  by  the  Holzkuecht 
method,  and  that  the  color  may  change  by  the  action  of  heat,  light, 
moisture,  etc.  It  is  asserted  by  some  that  the  location  where  the 
pastille  is  placed  under  the  active  hemisphere  may  not  be  equally 
irradiated,  because  the  rays  are  unequally  distributed  over  the  active 
hemisphere. 

The  Cliromoradiometer  of  Bordier. — Bordier1  describes  a  new  method, 
based  on  the  principle  that  when  platiuo-cyanide  of  barium  is  exposed  to 
the  rays,  it  undergoes  a  change  of  color  due  to  the  dehydrating  action  of 
the  X-rays,  also  that  the  same  discoloration  occurs  when  this  chemical  is 
placed  in  an  atmosphere  artificially  dried  by  sulphuric  acid  or  when  ex- 
posed to  a  gradually  increasing  temperature.  Under  the  action  of  light 
dehydration  may  also  occur.  He  describes  his  apparatus  and  reagent  as 
follows:  "  The  Bordier  chromoradiometer  differs  from  its  predecessors. 
The  barium-platino-cyanide,  suspended  in  a  thin  layer  of  collodion,  is 
placed  on  the  skin  itself,  or  at  all  events  in  the  same  plane  as  the  part 
to  be  irradiated.  The  pastilles  are  square,  with  a  diameter  of  6.5  milli- 
metres. The  back  of  the  square  is  adhesive,  to  facilitate  its  attachment 
to  the  skin.  A  scale  of  colors  is  supplied  with  tints  Xos.  1,  2,  3,  4,  cor- 
responding to  the  principal  reactions  required  in  radiotherapy. 

"Tint  No.  1,  a  pale  yellowish-green,  is  the  shade  that  the  pastille 
takes  when  exposed  to  the  maximum  dose  of  rays  compatible  with  the 
complete  integrity  of  the  normal  skin.  "NYith  this  dose  of  X-rays  the  hair 
falls  out  some  twenty  days  after  exposure,  and  grows  again  within  the 
succeeding  twenty  days.  This  is  the  weak  normal  exposure  of  Kien- 
bo'ck's,  corresponding  to  a  skin  reaction  of  the  first  degree,  accompanied 
by  temporary  loss  of  hair. 

"Tint  No.  2,  of  a  sulphur-yellow  shade,  is  that  color  the  pastille 
assumes  when  the  skin  has  been  exposed  to  an  irradiation  calculated  to 

1  Archives  of  the  Riintgen  Ray,  June,  1906,  p.  9. 


434  ELECTRO-THERAPEUTICS. 

produce  a  strong  reaction,  viz.  erythema,  tumefaction,  and  at  the  end  of 
the  reaction  marked  desquamation.  This  Xo.  2  tint  corresponds  to  a  mild 
form  of  Kienbock's  reaction  of  the  second  degree. 

"Tint  No.  3  is  almost  of  the  color  of  gamboge.  It  corresponds  to  a 
reaction  of  the  skin  of  the  second  degree  ;  it  is  a  true  dermatitis.  Latent 
period  is  eight  to  ten  days.  This  is  Kienbock's  strong  normal  reaction. 

"Tint  No.  4  is  of  a  chestnut  color,  and  corresponds  to  a  reaction  of 
the  third  degree,  which  is  accompanied  by  necrosis  and  ulceration  of  the 
skin.  This  is  the  strongest  dose  ever  required  and  should  never  be 
applied  to  the  normal  skin.  He  obtained  tint  No.  4  after  irradiation  of 
a  specimen  of  radium  of  a  radio-activity  of  100,000  for  a  week,  at  a 
distance  of  a  millimetre  from  two  pastilles." 

Very  soft  tubes  are  not  desirable  for  these  reagents,  as  they  produce 
ultra-violet  rays  which  will  be  confused  with  the  X-rays.  He  reports 
cases  that  were  cured  at  a  single  seance.  He  believes  in  giving  one 
massive  dose  rather  than  fractional  doses,  so  common  in  this  country. 
This  method  is  also  subject  to  the  same  objections  that  I  have  mentioned 
before. 

Quantimeter  of  Kienbock. — In  1905  Dr.  R.  Kienbock  introduced  this 
new  method  of  direct  dosimetry,  and  asserted  that,  in  1900,  he  demon- 
strated that  the  changes  noted  on  a  photographic  plate  are  an  accurate 
measure  of  the  therapeutic  dose ;  admitting,1  however,  that  Stern2  pub- 
lished a  paper  on  photo-radiornetry,  and  suggested  the  use  of  photo- 
graphic films,  to  be  compared  with  a  "  normal  scale  ;"  but  at  that  time 
(1905)  Kienbock  was  unaware  of  the  fact.  He  describes  his  instrument  as 
follows : s  "My  quantimeter  (Fig.  221)  consists  essentially  of  two  parts,  a 
strip  of  photographic  paper,  which  is  easily  applied  to  the  irradiated 
skin,  and  a  normal  scale  of  graduated  tints,  with  which  it  is  to  be  com- 
pared. The  paper  is  covered  with  a  sensitized  film  of  chloro-bromide  of 
silver  in  gelatine.  After  exposure,  the  strip  may  be  developed  in  a  dark 
room  or  by  means  of  a  small  light-proof  box.  The  development  can  be 
carried  on  in  daylight  in  the  consulting  room.  The  film  is  then  compared 
with  the  standard  scale,  either  at  once  or  after  drying.  The  developing 
solution  is  of  constant  composition,  and  should  be  used  at  a  temperature 
of  18°  C.,  or  64°  F.,  for  a  period  of  exactly  one  minute.  After  fixation, 
the  strip  of  paper  may  be  immediately  compared  with  the  scale."  The 
unit  of  Rontgeu  light  which  we  call  X  is  equivalent  to  one-half  of  a  Holz- 
knecht  unit  and  to  one-tenth  of  the  Sabouraud-Noir6  maximum  dose. 
The  formula  is  as  follows  :  1  S-N  maximal  dose  =  5  H  or  10  X. 

This  reagent  enables  us  to  measure  the  penetration  or  the  degree 
of  hardness  of  the  Rontgen  light.  In  comparison  with  other  dosimetric 

'Archives  of  the  Rontgen  Ray,  June,  1906,  p.  17. 
2  Journal  of  Cutaneous  Diseases,  December,  1903. 
8  Archives  of  the  Rontgen  Ray,  June,  1906,  p.  17. 


TECHNIC  OF  RONTGEN  RAY  THERAPY. 


435 


methods,  the  quantimetric  method  has  the  advantage  of  greater  exact- 
ness and  the  possibility  of  estimating  small  differences  of  dosage.  This 
method  gives  a  permanent  registered  record.  The  disadvantage  of  this 
method  is  the  difficulty  which  is  encountered  in  comparing  and  distin- 
guishing the  slight  differences  of  tint  on  the  scale.  Careful  development 
is  necessary  and  always  tedious.  When  massive  doses  are  given  the 
color  will  be  darker  and  will  be  more  difficult  for  making  comparison 
with  the  scale.  The  degree  of  the  sensitiveness  of  the  emulsion  of  the 
paper  may  frequently  differ. 

The  New  Radiometer  of  Freund. — Freund's  method  was  used  in  1904, 
and  is  based  on  the  color  changes  occurring  in  a  two  per  cent,  solution  of 


FIG.  221.— Kienbock's  quantimeter. 

pure  iodoform  in  chloroform.  This  solution  normally  retains  its  color 
unchanged  for  48  hours,  and  is  so  very  sensitive  that  a  difference  of  tint 
may  be  observed  between  two  portions  of  the  solution,  one  of  which  is 
exposed  to  the  rays  for  three  minutes,  while  the  other  portion  is  screened 
from  the  action.  Slight  heat  and  light  will  alter  the  color  of  the  solution, 
and,  although  this  method  is  most  accurate  and  sensitive,  the  solution  is 
too  unstable  for  practical  and  clinical  purposes. 

The  iodoform  (CHI3)  is  decomposed  by  the  X-rays,  with  the  libera- 
tion of  free  iodine,  imparting  a  claret-color  to  the  solution.  Freund's 
solution  shows  a  change  of  tint  in  six  minutes,  equal  to  that  attained  in 
ten  minutes  by  the  use  of  Holzknecht's  pastilles. 


436  ELECTRO-THERAPEUTICS. 

Precipitation  Test. — Schwartz,1  of  Vienna,  demonstrated  a  method 
of  measuring  the  strength  of  the  Rontgen  rays,  based  on  the  precipita- 
tion of  calomel  in  a  mixture  of  ammonium  oxalate  and  corrosive  subli- 
mate. This  mixture  is  a  clear  fluid  which,  sheltered  from  the  light,  keeps 
indefinitely.  Exposure  to  daylight  or  to  the  Rontgen  rays  causes  the 
precipitation  of  calomel.  The  amount  of  precipitation  is  determined  by 
centrifuging  in  a  graduated  capillary  tube.  Three  millimeters  of  the 
precipitate  in  the  capillary  tube  correspond  (approximately)  to  the 
strength  of  a  Holzknecht  unit.  This  technic  with  the  usual  methods 
of  testing  the  strength  of  the  latter  has  the  disadvantage  of  being  a 
subjective  test  of  color. 

D.  THE  IONIZATION  METHOD. 

Prof.  Rontgen,  in  his  second  announcement,  stated  that  he  had  already 
made  this  discovery,  and,  probably  prior  to  this,  J.  J.  Thomson  found  that 
the  X-rays  would  discharge  both  positively  and  negatively  electrified 
bodies,  by  experiments  on  Hankel's  electroscope  or  electrometer.  Thom- 
son stated  that  the  discharge  varied  somewhat  with  the  intensity  of  the 
rays  by  the  relative  luminosity  of  the  fluorescent  screen,  and  in  several 
instances  by  the  relative  darkness  produced  upon  the  photographic  plat*-. 
This  method  is  based  on  the  principle  that  X-rays  have  the  power  to 
ionize  the  gases  through  which  they  travel. 

The  lonization  of  Confined  Gases. — Milton  Franklin*  states  that,  "so 
far  as  I  have  been  able  to  ascertain,  this  method  has  not  been  system- 
atically used  to  measure  the  intensity  of  the  X  rays.  This  method  has 
been  commonly  employed  to  measure  the  radio-activity  of  radio-active 
substances.  Air  is  rendered  a  conductor  of  electricity  by  this  ionizing 
agent,  and  the  measurement  of  the  amount  of  current  flowing  through 
it,  under  given  conditions,  gives  an  absolute  index  of  the  activity  of  the 
radiation.  It  is  necessary  only  to  charge  the  electroscope  by  applying  a 
rod  of  vulcanite,  sealing-wax,  resin,  or  other  suitable  material,  which  has 
been  previously  electrified  by  friction,  and  then  to  time  the  transit  of 
the  filament  under  the  influence  of  X-rays.  The  rate  of  discharge  will 
vary  directly  as  the  activity  of  the  radiation." 

The  working  of  the  instrument  is  as  follows : 

"  The  electroscope  is  charged  by  having  brought  into  contact  with 
the  knob,  a  rod  of  vulcanite  which  has  been  electrified  by  friction.  The 
knob  is  brought  into  communication  with  the  filament  while  the  vulcanite 
is  in  contact,  and  released  as  soon  as  the  filament  has  assumed  a  horizon- 
tal position.  The  electroscope  is  brought  to  the  same  distance  from  the 
tube  as  the  plate  or  patient  (in  any  position),  and,  while  the  tube  is  run- 
ning, the  shutter  is  opened,  and  the  time,  in  seconds,  occupied  by  the 

1  Wiener  klin.  Woch.,  May  31,  1906. 

1  New  York  Medical  Journal,  April  22,  1905. 


TECHXIC  OF  KOXTGEX  BAY  THERAPY.  437 

filament  in  transit,  is  noted.  The  number  of  seconds  is  the  exact 
coefficient  of  energy  of  the  rays,  and  when  compared  with  any  other 
reading  made,  under  any  circumstances  whatever,  with  a  similar 
instrument,  the  ratio  of  energy  of  the  two  radiations  will  equal  that  of 
the  two  times. 

"In  this  method,  with  an  electroscope  of  the  gold-leaf  pattern, 
the  relative  activities  of  two  radiations  may  be  compared  with  great 
accuracy  and  expedition,  and  if  one  of  them  is  the  standard  unit  of 
activity  or  bears  a  known  ratio  to  the  standard,  the  value  of  the  other, 
in  terms  of  the  standard,  will  be  readily  deducible.  Atmospheric 
variations  must  be  taken  into  consideration.  The  number  of  seconds 
which  it  requires  for  the  filament  to  traverse  the  field,  is  the  coefficient 
of  the  strength  of  the  rays.  All  calculations  and  variations  due  to 
the  atmospheric  absorption  must  be  eliminated  at  once." 

Tfie  Radio-active  Standard  of  Phillips. — Phillips1  utilizes  the  principle 
of  Franklin's  method  of  ionization,  and  suggests  radium  as  the  standard 
unit.  He  describes  the  modus  operandi  as  follows:  "The  method  con- 
sists in  attaching  two  similar  discharge  vessels  one  to  each  of  the  plates 
of  the  electroscope.  The  needle,  a  thin  strip  of  silvered  mica,  is  only 
electrified  inductively,  and  the  forces  acting  upon  that  end  of  it  which 
comes  to  rest  above  the  centre  of  the  gap  are  able,  Avheu.  the  rods  are 
electrified  equally,  to  produce  a  condition  of  equibirium.  The  horizontal 
rods  are  connected  with  the  standard  radium  ;  when  the  rods  are  equally 
charged,  the  needle  is  steady,  but  gives  no  deflection.  *  *  *  We 
may  also  conveniently  compare  the  activities  of  various  substances,  by 
noting  the  time  taken  for  a  gold-leaf  electroscope  to  discharge  between 
certain  potentials.  To  do  this  with  anything  approaching  accuracy, 
however,  the  motion  of  the  leaf  must  be  observed  with  a  reading  tele- 
scope." He  calls  the  absolute  unit  the  Becquerel,  or  one  Curie,  while 
the  commercial  unit  might  be  appropriately  known  as  one  "ray." 

Dr.  Henry  G.  Piffard*  takes  a  brass  ball,  about  one  and  one- 
quarter  inches  in  diameter,  and  supports  it  about  four  inches  from 
the  wall  of  the  tube  just  within  the  circle  of  rays  issuing  from  the  ante- 
rior hemisphere.  The  ball  is  then  connected  by  a  cord  about  eight  feet 
long  to  the  charging  device  of  the  electroscope.  As  soon  as  the  current 
passes  through  the  tube  the  aluminium  needle  or  foil  indicates  the 
charge,  and  the  angle  is  easily  read  off  on  the  scale.  For  this  purpose 
he  found  Brauirs  electroscope  (which  is  graduated  in  volts)  or  his 
own  (which  is  graduated  in  degrees  of  an  arc)  very  convenient.  The 
angle  varies  directly  with  the  current  passing  through  the  tube,  and 
also  shows  whether  the  tube  is  running  steadily  or  not,  and  indicates 
any  notable  change  in  the  vacuum. 

1  Archives  of  the  Rontgen  Ray,  June,  1906,  p.  27. 

2  Journal  of  the  American  Medical  Association,  Sept.  15,  1906. 


438  ELECTRO-THERAPEUTICS. 

E.  THE  PHOTOMETRIC  METHODS. 

These  methods  consist  in  comparing  the  fluorescence  of  a  platiuo- 
barium  cyanide  screen  with  an  artificial  light,  either  with  a  fluorescence 
produced  by  radium  or  a  radio-active  salt. 

The  Radiometer  of  Courtade. — This  instrument  consists  of  a  lead  shield 
containing  two  similar  openings,  and  covered  by  a  fluorescent  screen.  The 
radium,  which  serves  as  a  standard  of  fluorescence,  is  placed  behind  one 
aperture.  The  degree  of  fluorescence  on  the  second  screen,  produced  by 
the  X-rays,  is  equalized  with  that  of  the  standard  by  altering  the  dis- 
tance of  the  Crookes  tube.  This  distance  will  be  a  measure  of  the  amount 
and  the  quality  of  the  radiation.  This  method  is  not  thoroughly  or  ab- 
solutely correct,  because  the  intensity  of  the  fluorescence  of  all  the 
platino-barium  cyanides  is  subject  to  great  variations,  when  exposed  for  a 
long  time  to  the  action  of  radium  or  the  X-rays. 

The  GuiUeminot- Courtade  Method. — Founded  on  the  same  principle  as 
the  radiometer  of  Courtade,  Guillemiuot  employs  a  sample  of  radium  as 
his  standard  of  comparison,  whose  activity  is  50,000.  He  considers  the 
unit  of  quantity  of  the  X-ray  is,  that  quantity  falling  on  one  square  centi- 
metre of  the  surface  in  one  minute  of  time.  This  unit  he  calls  the  unit 
"M."  For  example,  if  the  Crookes  tube  has  to  be  placed  at  a  distance 
of  3  metres,  in  order  to  produce  an  equal  illumination  of  the  screen, 
then  the  intensity  of  irradiation  of  the  field  at  3  metres  from  the  tube  is 
said  to  be  unity.  From  this  it  is  easy  to  calculate  the  number  of  units 
"M"  absorbed  per  minute  at  a  distance  of  10,  15,  or  20  centimetres. 
Thus,  in  the  above  example  the  number  of  units  absorbed  per  minute  at 

10  centimetres  distance  is  900, "M"  =  3  metres  (300  cm.)  ;  then  3(*> cm-  = 

10  cm. 

30  cm.,  therefore  30  cm.  x  30  cm.  =  900,  while  at  15  cm.  it  is  400,  etc.1 
This  is  open  to  the  many  objections  mentioned  before,  the  platino- 
barium-cyanide  changing  its  color  of  fluorescence,  etc.  This  does  not 
give  us  the  amount  of  absorption  in  the  tissue,  but  we  infer  that  from 
calculations  deduced. 

The Fluorometer of  Williams. — This  instrument*  depends  upon  the  dis- 
tance that  a  tungstate  of  calcium  screen  must  be  held  from  a  given 
vacuum  tube,  in  order  that  the  illumination  from  it  may  equal  that  from 
a  radio-active  substance  which  has  been  measured  by  a  standard  source 
of  light.  "I  found,"  says  Williams,  "that  when  a  tungstate  of  calcium 
screen  with  the  radium  (Curie)  lying  upon  it  was  placed  over  a  vacuum 
tube  in  a  dark  room,  and  the  X-rays  allowed  to  strike  it,  the  radium  was 
less  bright  than  the  luminous  screen ;  but  that  as  the  screen  was  moved 
farther  away  from  the  vacuum  tube,  the  brightness  of  the  screen  diminished 
until  a  point  was  reached  at  which  the  screen  was  less  bright  than  the 

1  Archives  of  the  Rontgen  Ray,  June,  1906. 

2  The  Rontgen  Rays  in  Medicine  and  Surgery,  1903,  p.  640. 


TECHNIC  OF  EONTGEN  BAY  THEKAPY.  439 

radium,  and  that  then  by  gradually  approaching  the  screen  nearer  the 
vacuum  tube  a  point  was  found  at  which  the  radium  and  screen  were 
about  equally  bright. 

"I  experimented  with  several  tubes  in  this  way,  and  found  that  the 
distance  at  which  the  screen  and  the  radium  were  about  equally  bright 
was  different  with  different  tubes,  the  limit  of  variation  being  between 
10  and  41  centimetres  ;  and  the  distance  was  constant  for  the  same  tube 
under  the  same  conditions.  As,  by  means  of  a  photometer,  the  amount  of 
light  given  off  by  the  radium  can  be  measured  in  terms  of  a  known  stand- 
ard, so  the  amount  of  fluorescence  produced  on  a  tungstate  of  calcium 
screen  by  a  given  tube  and  the  brightness  of  which  a  given  screen  is 
capable  may  both  eventually  be  referred  to  the  same  standard.  The 
fluorometer  may  serve  as  a  basis,  with  a  given  apparatus,  for  determining 
the  length  of  exposure  when  X-rays  are  used  as  a  therapeutic  agent,  and 
likewise  when  they  are  employed  for  taking  radiographs." 

This  instrument  has  the  objection  that  the  durability  of  tungstate  of 
calcium  varies  with  different  tubes,  and  also  because  the  vacuum  of  the 
tube  changes  during  exposure  and  requires  constant  attention. 

The  Method  of  Contremoullns. — With  this  method,  instead  of  employ- 
ing radium,  the  standard  fluorescent  screen  is  illuminated  by  an  acetylene 
light.  This  is  open  to  the  same  objection  as  stated  above. 

Selenium  Photometer, — In  1905  Euhmer  Levy  presented,  at  the  Berlin 
Congress,  a  new  instrument  for  measuring  the  X-rays.  A  selenium  cell  is 
clamped  in  position  at  a  fixed  distance  from  the  anode,  a  current  from  a 
couple  of  dry  cells  is  passed  through  the  selenium,  and  its  intensity  is 
read  off  on  a  millianiperenieter.  The  X-rays  alter  the  resistance  of  the 
selenium,  and  the  variation  of  the  current  is  therefore  a  measure  of  the 
quantity  of  the  rays. 

Dunham's  instrument1  consists  of  a  selenium  cell,  which  is  placed 
inside  of  a  wooden  pill-box  and  surrounded  by  tungstate  of  calcium. 
This  and  a  voltmeter  are  placed,  in  series,  in  a  direct  current  of  not  less 
than  60  volts.  When  this  is  placed  before  an  X-ray  tube,  the  tungstate  of 
calcium  is  caused  to  fluoresce  and  the  light  derived  from  the  fluorescence 
causes  the  resistance  of  the  selenium  cell  to  be  reduced.  The  fluorescence 
is  much  less  powerful  than  a  15 -candle-power  lamp.  This  lowering  of 
resistance  in  the  cell  allows  the  current  to  flow  more  readily,  and  this  can 
be  directly  measured  by  a  very  sensitive  voltmeter.  The  next  instru- 
ment depends  for  its  action  on  the  fact  that  a  2-per  cent,  solution  of  iodo- 
forni  in  chloroform  is  very  easily  and  uniformly  affected  by  the  X-rays. 
Its  appearance  when  so  treated  varies  from  a  light  pink  to  a  very  dark 
reddish  brown.  The  second  instrument  is  as  follows  :  The  selenium  cell 
and  voltmeter  are  put  in  series  as  before,  but  no  fluorescent  salt  is  used. 
The  wooden  box  is  removed  and  the  cell  placed  in  a  light,  tight  box.  The 

'Lancet-Clinic,  Cincinnati,  August  25,  1906. 


440 

resistance  of  the  selenium  cell  is  reduced  by  the  electric  lamp  beyond  a 
partition.  The  light  must  pass  from  a  lamp  to  the  cell  through  the  bottle 
because  of  the  small  aperture.  To  make  this  doubly  certain  the  opening 
is  fitted  with  a  small  cylinder  so  that  the  rays  must  pass  as  desired. 
When  it  is  desired  to  measure  a  given  dosage,  all  that  is  necessary  to  do  is 
to  fill  the  bottle,  place  it  in  the  box,  and  make  the  reading.  The  solution 
is  clear  and  practically  all  the  light  passes  to  the  cell.  The  resistance 
drops  and  the  voltage  as  read  on  the  meter  goes  up.  The  bottle  is  now 
removed  and  laid  on  the  surface  of  the  patient  near  the  part  to  receive 
the  irradiation.  After  the  treatment  it  is  quickly  placed  in  the  box  and 
the  reading  taken.  The  quantity  of  X-rays  will  be  read  by  the  difference 
of  the  voltage  before  and  after  the  exposure. 

Dr.  George  G.  Johnston1  takes  advantage  of  the  fluorescence  pro- 
duced on  the  tungstate  of  calcium  or  other  screen  as  indicating  the 
quantity  of  the  X-rays  emitted.  The  fluorescing  screen  is  placed  in  a 
light,  tight  box,  and  facing  it  is  a  selenium  cell.  Such  a  cell,  when  kept 
in  total  darkness,  may  have  the  resistance  of  several  hundred  ohms,  yet 
on  permitting  light  to  strike  the  cell  resistance  falls  almost  instantly, 
and  this  alteration  bears  a  direct  relation  to  the  intensity  of  the  light.  If 
there  is  placed,  in  series,  with  such  a  cell  a  galvanometer  or  ammeter  of 
sufficient  delicacy,  a  series  of  current  such  as  an  ordinary  dry  battery 
and  a  variable  rheostat  providing  a  means  of  introducing  more  or  less 
ohmic  resistance  into  the  circuit,  and  the  rheostat,  the  measuring  instru- 
ment, and  the  selenium  cell  be  balanced,  the  point  will  be  found  at  which 
the  ohmic  resistance  of  the  rheostat,  the  communicating  wires,  the 
selenium  cell,  and  the  measuring  instrument  will  exactly  balance  the 
electro-motive  force  of  the  battery. 

If,  however,  the  container,  having  within  it  the  screen  and  cell,  be 
placed  in  the  path  of  the  X-rays,  the  screen  will  become  luminous  in  pro- 
portion to  the  distance  from  the  source  of  the  rays  and  the  quality  of 
rays  striking  it.  The  container  will  be  illuminated ;  the  selenium  cell 
under  the  influence  of  this  light  will  change  its  ohmic  resistance  in  pro- 
portion to  the  light,  and  the  current  flow  will  be  measured  and  indicated 
on  the  dial  of  the  galvanometer. 

Fluorescence  of  the  Tube  and  the  Appearance  of  the  Electrodes. — This 
method  does  not  afford  a  reliable  means  of  determining  the  penetrability 
of  the  rays,  as  the  fluorescence  depends  upon  the  kind  of  glass  composing 
the  tube.  In  a  dark  room  this  fluorescence  will  be  more  clearly  discern- 
ible. Behind  the  anode  there  may  often  be  noticed  annular  patches  of 
fluorescence,  indicating  a  high  vacuum.  In  studying  the  appearance 
of  the  electrodes,  a  phenomenon  sometimes  noticed  is,  the  emission  of  a  fine 
smoky  stream  around  the  edge  of  the  cathode  ;  indicating  a  high  degree 
of  vacuum.  A  low  vacuum  in  the  tube  can  be  recognized  by  a  conical 

'Journal  of  the  American  Medical  Association,  September  15,  1906. 


TECHNIC  OF  RONTQEN  BAY  THERAPY.  441 

stream  of  cathode  rays  of  a  blue  color.  The  appearance  of  a  cherry-red 
heat  at  the  anode  indicates  that  the  tube  is  working  properly,  and  that 
rays  of  a  high  degree  of  penetrability  are  being  produced.  However, 
this  will  vary  according  to  the  thickness  of  the  platinum  anode  and  the 
strength  of  the  current.  It  should  not  be  forgotten  that  the  same  tube 
will  fluoresce  differently  with  the  different  amounts  of  current,  which 
will  produce  more  or  less  penetrating  rays. 

The  Thcrmomelric  ^^(iho(L  —  Kohler  places  a  thermometer  into  a 
depression  in  the  Crookes  tube,  whereby  he  gauges  the  variation  of 
temperature  as  indicative  of  the  quality  and  quantity  of  the  rays. 

III.   Natural   Fluorescence    in   the    Human  Body  and   its  Artifi- 
cial Production.1 

Fluorescence  may  be  defined  as  a  property  possessed  by  certain  sub- 
stances of  absorbing  visible  or  invisible  rays  and  emitting  visible  light. 
Fluorescence  and  phosphorescence  are  not,  however,  synonymous,  in  that 
the  former  is  evidenced  only  when  the  exciting  cause  is  acting,  and  that 
the  latter  continues  after  the  cessation  of  the  exciting  force.  Long  ago  it 
was  asserted  and  proved  that  a  natural  fluorescence  existed  in  the  tissues 
of  the  human  econonvy.  The  crystalline  lens,  the  cornea,  the  aqueous 
and  vitreous  humors  are  all  fluorescent.  Again,  it  has  been  demon- 
strated repeatedly  that  the  liver,  heart,  lungs,  spleen,  kidneys,  brain, 
muscles,  nerves,  etc.,  contain  a  fluorescent  material,  in  many  respects 
resembling  quinine,  to  which  the  name  of  lt  animal  quinodin  "  has 
been  applied.  Half  a  century  ago  the  view  was  advanced,  and  still  very 
largely  obtains,  that  an  intimate  relation  exists  between  the  decrease  of 
animal  quiuodin  and  malarious  affections  ;  therefore  the  apparent  wisdom 
of  exhibiting  quinine  to  augment  the  fluorescence  of  the  devitalized  tis- 
sue to  its  normal  point.  Based  upon  these  views,  experiments  were 
instituted  and  malarious  patients  were  treated  in  darkened  rooms  with 
purple  hangings,  in  the  belief  that  the  sporulation  of  the  plasmodiuin  of 
malaria  could  not  occur  in  the  absence  of  light,  and  especially  red  light, 
corresponding  to  the  Finsen  treatment  of  smallpox.  Thus,  from  the  de- 
ductions of  various  observers  and  experimenters,  the  administration  of 
fluorescent  substances  has  been  tried,  and  the  blood  thus  affected  has  been 
the  subject  of  an  interesting  study  both  by  the  X-rays  and  with  radium. 
The  fluorescent  substances  must  of  course  be  harmless,  and  a  radiation 
employed  capable  of  offering  a  fluorescence  deep  within  the  tissues. 
Sunlight,  electric  discharges,  the  ultra-violet  rays,  the  X-rays,  and  the 

1  This  subject  has  been  most  exhaustively  and  elegantly  investigated  by  Dr. 
"William  James  Morton,  of  New  York  City.  For  a  clear  exposition  of  the  study,  the 
reader  is  referred  to  Morton's  original  paper,  "  Fluorescence  Artificially  Produced  in 
the  Human  Organism,"  Journal  of  the  American  Medical  Association,  April  1,  1905, 
from  which  parts  of  the  above  article  have  been  taken. 


442  ELECTRO-THERAPEUTICS. 

Becquerel  rays  are  all  capable  of  exciting  fluorescence  and  phosphores- 
cence within  the  human  body.  For  a  study  of  the  physiological  action 
of  light  upon  animals  and  plants,  the  reader  is  referred  to  the  chapter 
devoted  to  "  Phototherapy." 

APPLICATION  IN  DISEASE. 

As  a  therapeutic  agent,  Dr.  Morton  says  :  "  I  employ  quinine  bisul- 
phate  in  doses  of  from  five  to  fifteen  grains  daily,  according  to  the 
natural  physiologic  tolerance  of  the  patient ;  fluorescin,  a  1  to  30 
aqueous  solution,  from  six  to  twenty  drops,  three  times  daily,  one  hour 
after  meals  ;  esculin,  from  five  to  fifteen  grains  daily. 

"In  treatment  of  an  extremely  obstinate  case  of  lupus,  one  patient 
has  now  taken  ten  drops  of  the  fluoresciu  solution  three  times  daily  dur- 
ing the  last  three  months  and,  employing  the  X-ray,  not  only  has  his 
lupus  healed  over  large  areas,  but  he  also  has  gained  thirty  pounds  in 
weight  in  the  three  months.  Both  in  hospital  and  in  private  practice  my 
cases  of  lupus  heal  more  rapidly  and  get  permanently  cured  by  this 
method  and  in  less  time  than  by  any  other  method  I  have  used. 

' '  I  have  ready  to  report  six  patients  with  tuberculous  glands  of  the 
neck,  two  already  subjected  unavailingly  to  numerous  surgical  operations 
for  removal,  who  are  now  perfectly  well.  One  case  of  tuberculosis  of  the 
hip -joint  is  making  marked  improvement. 

11  In  tuberculosis  of  the  lungs  the  method  is  giving  good  results,  not 
yet  ready  to  be  reported  on  in  extenso. 

"In  from  one  to  three  days  after  beginning  treatment  a  reaction 
occurs.  The  afternoon  temperature  in  a  recent  case  rose  from,  normal  to 
103°  F.  The  cough,  night  sweats,  and  lassitude  increased.  Examination 
of  the  sputum  at  this  time  revealed  an  enormous  increase  of  the  number 
of  tubercle  bacilli.  This  reaction  lasted  about  a  week  and  then  the  tem- 
perature gradually  fell  to  normal,  with  corresponding  improvement  in 
the  other  symptoms.  The  patient  then  entered  on  a  stage  of  steady 
gain  in  weight  and  comfort  and  personal  appearance.  The  case  is 
under  most  rigid  observation  by  skilled  consultants  and  will  be  reported 
on  later." 

Morton  asserts  that  the  fluorescence  is  much  increased  if  radio- 
active water  is  used  to  prepare  fluorescent  solutions.  He  administers 
a  half  ounce  of  radio-active  water  in  the  morning,  and  again  in  the 
evening,  believing  that  this  liquid  absorbs  and  holds  the  emanations  of 
radium,  becoming  a  secondary  source  of  radiation ;  the  charged  water 
exciting  the  fluorescence.  He  successfully  combats  those  scientists  who 
deny  the  possible  existence  of  a  radio-active  fluid. 

As  is  usual  in  such  studies,  the  mass  of  literature,  good,  bad,  and 
indifferent,  upon  the  subject  in  hand  is  most  confusing.  I  append  Dr. 
Morton's  resum6 :  "The  excitation  of  fluorescence  within  tissue  is  a 


TECHXIC  OF  BOXTGEX  EAY  THEEAPY.  443 

species  of  phototherapy  and  dependable  on  the  same  basis  for  curative 
effects.  The  term  sensitization  is  not  accurate,  for  it  is  not  known  what 
the  term  means.  There  is  no  proof  that  fluorescent  substances  make 
the  cells  or  other  micro-organisms  vulnerable  to  the  exciting  radiation. 

••  \\liat  the  fluorescent  light  lacks  in  intensity  is  compensated  for  by 
propinquity  to  tissue. 

"The  method  here  outlined  consists  of  a  medicinal  saturation  of 
the  entire  blood  system  with  a  fluorescent  solution,  and  submission  of 
parts  or  of  the  whole  of  the  patient  to  the  Boutgen  and  Becquerel 
radiations,  and  to  electric  discharges. 

"The  method  naturally  includes  filling  cavities  with  fluorescent 
solutions,  as  well  as  using  these  solutions  medicinally. 

"The  curative  effects  obtained  by  this  method  are  probably  due 
to  the  fluorescent  light.  This  method  permits  of  an  improvement  in 
skiagraphic  effects  and  of  fluoroscopic  examinations. 

"Following  the  suggestions  of  the  use  of  fluorescent  solutions  in 
diagnosis  and  treatment,  the  method  has  proved  of  value  in  determining 
the  position  and  size  of  the  stomach  and  other  cavities  of  the  body. 

"The  thoracic  cavity  presents  on  the  fluoroscope  a  degree  of  illumi- 
nation greater  than  that  produced  by  the  X-radiatiou  alone. 

"The  method  is  useful  in  tuberculosis  of  the  lungs,  and  in  other 
cases  of  tuberculous  deposits,  as  well  as  in  cancer." 

Influence  of  Photodynamic  Substances  on  the  Action  of  X-  Rays. — Kothe1 
is  enthusiastic  over  the  enhanced  action  of  the  X-rays  after  the  tissues 
have  been  previously  injected  with  a  one  per  cent,  or  per  thousand  solu- 
tion, of  eosin,  an  hour  before  exposure.  He  describes  experiments  on 
animals,  and  with  lupus  and  warts  in  the  clinic.  The  injection  of  eosin 
enables  the  course  of  X-ray  treatment  to  be  much  shortened,  the  expo- 
sure need  not  be  so  long,  and  the  reaction  occurs  sooner  and  is  more 
intense  than  without  the  eosin.  The  eosin  injections  also  permit  the  ener- 
getic reaction  to  be  restricted  to  a  circumscribed  area,  while  the  unin- 
jected,  sound  tissue  around  or  above  scarcely  feels  the  action  of  the  rays. 

Theoretically  this  method  of  treatment  seems  very  plausible.  Prac- 
tical tests  of  its  value  have  fallen  far  short  of  the  early  expectations. 
This  is  probably  due  to  the  fact  that  such  quantities  of  fluorescent  salts 
as  can  be  absorbed  are  so  widely  distributed  and  diluted  in  the  fluids  of 
the  body  that  no  appreciable  effects  can  be  produced.  The  same  dilu- 
tion, approximately,  employed  experimentally  outside  the  body  fails  to 
give  any  reaction  on  photographic  plates.  The  effects  produced  on  the 
patient  by  the  administration  of  quinine  are  probably  due  to  its  anti- 
toxic action,  counteracting  the  toxins  resulting  from  efficient  Bontgen 
treatment  and  the  consequent  break-down  and  absorption  of  diseased 
tissues. 

1  Deutsch.  me«l.  Woch.,  Berlin,  vol.  ix.,  1904. 


CHAPTER  V 
THEKAPEUTIC  VALUE  IX   DISEASE. 

I.  Cutaneous  Affections. 
LUPUS  ERYTHEMATOSUS. 

IN  the  first  case  of  lupus  erytheniatosus  treated  with  the  X-rays,1 
the  method  employed  was  precisely  the  same  as  that  used  in  cases  of 
lupus  vulgaris.  The  result  was  a  rapid  disappearance  of  the  cellular 
infiltration  in  those  areas  exposed  to  the  direct  action  of  the  rays.  Im- 
mediately surrounding  this  area  a  ring  of  pigmentation  forms,  which, 
however,  quickly  disappears.  The  skin  remains  perfectly  flat,  regular, 
and  practically  normal  after  the  rays  have  been  discontinued. 

Jutassy  *  reported  a  case  of  lupus  erytheniatosus  in  which  he  effected 
an  absorption  of  the  infiltrating  cellular  elements,  deposited  by  the  capil- 
laries of  the  coriuin  and  of  those  of  the  corpus  capillare.  A  partial  recur- 
rence of  small  extent  was  observed  in  those  portions  which  the  rays  had 
difficulty  in  reaching. 

Hahn  and  Grouven s  report  successful  results  obtained  in  cases  of 
lupus  erytheniatosus,  as  do  likewise  Sjogren,4  Sartin,s  and  Torok  and 
Schein.' 

LUPUS  VULGARIS. 

That  the  X-rays  are  most  beneficial  in  the  treatment  of  lupus  vulgaris 
is  to-day  the  consensus  of  opinion  among  dermatologists.  Freund 
and  Schiff  were  the  first  to  give  a  detailed  account  of  the  favorable 
influence  of  the  X-rays  in  this  disease.  The  rays  seem  to  have  a 
selective  action  on  the  tubercles,  and  in  continued  treatments  cause 
a  sloughing  off  of  the  hardened,  gummy  masses,  which  in  time  are 
replaced  by  healthy  scar  tissue.  The  deduction  of  Freund  in  two  cases 
treated  by  him  as  early  as  1897  is,  "that  there  is  primarily  set  up  an 
inflammatory  reaction  within  the  already  discovered  diseased  tissue  by 
the  rays/' 

After  irradiation  there  results  a  specific  reaction,  causing  the  tubercles 
to  become  visible  ;  this  is  followed  by  a  loosening  of  the  tubercles  with  an 

1  Fortechritte  der  Rontgenstrahlen,  vol.  ii.,  by  Dr.  E.  Schiff. 
1  Wanderversammlung  Ungarischer  Aerzte,  Aug.,  1899. 
'Aerztl.  Verein,  Hamburg,  1900. 

'Fortschr.  a.  d.  Geb.  d.  Rontgenstrahlen,  1901,  v.  p.  37. 
*  Lancet,  1901,  ii.  p.  144. 
•Wiener  med.  Wochen.,  1902,  lii.  p.  847. 
444 


THERAPEUTIC  VALUE  IX  DISEASE.  445 

increase  in  their  size,  due  to  an  augmented  blood  supply,  which  is  suc- 
ceeded by  a  shedding  of  the  masses.  With  the  swelling  of  the  tuberculous 
nodules  there  is  set  up  a  swelling  of  the  already  infiltrated  lymphatic 
glands  in  the  vicinity  of  the  tuberculous  area. 

Birkett '  treated  a  boy,  aged  15,  with  a  family  history  of  tuberculosis, 
who  had  two  distinct  primary  lupus  growths  in  the  oro-pharynx,  each 
situated  partly  on  the  lateral  and  partly  on  the  posterior  pharyngeal 
wall.  The  growths  were  distinctly  nodular  in  appearance,  about  the  size  of 
a  swollen  sago  grain.  Medical  and  surgical  measures  were  inefficient, 
and  resort  was  made  to  the  X-rays.  A  regulating  tube  with  a  vacuum 
equal  to  a  3-iuch  (7.5-cm.)  spark-gap  was  employed.  Twenty-three  daily 
exposures  were  given.  A  recurrence  was  treated  in  the  same  manner, 
and  the  results  at  the  present  time  are  most  satisfactory. 

In  cases  of  lupus  the  reaction  always  runs  a  similar  course,  the 
tubercles  gradually  swelling,  turning  dark  red,  and  becoming  turgescent ; 
at  the  same  time  irregular  dark  spots  develop  in  regions  previously  unaf- 
fected, which  subsequently  take  on  the  character  of  lupus  nodules.  These 
nodular  masses  subsequently  drop  out,  leaving  behind  cavities  with  a 
circular  punched-out  appearance  about  the  size  of  a  pin-head. 

The  results  are  on  the  whole  as  satisfactory  as  those  obtained  by 
Finsen's  method.  The  latter  may  give  better  results,  but  the  procedure 
is  more  or  less  tedious,  the  apparatus  is  expensive,  and  often  fails  to 
work  satisfactorily.  With  the  X-rays  a  larger  field  of  affected  skin  can 
be  treated  at  one  exposure  than  with  the  Finsen  light. 

M.  Morris  and  S.  E.  Dore2  state  that  "the  X-rays  have  a  sphere  of 
usefulness,  but  in  cases  of  lupus  they  are  much  inferior  as  a  curative 
agent  to  the  treatment  advanced  by  Finsen.  However,  the  rays  can  be 
applied  to  cavities  which  are  inaccessible  to  the  Finsen  light." 

E.  Smith3  reports  a  case  of  lupus  vulgaris,  of  fifteen  years'  standing, 
successfully  treated  and  apparently  cured  by  X-ray  irradiations.  The 
patient  was  a  man  of  eighty,  who  had  been  told  that  he  was  suffering 
with  a  cancer  of  the  right  side  of  the  nose,  the  inner  can  thus  of  the  right 
eye,  and  the  inner  thirds  of  the  lids.  Twelve  treatments  were  given, 
marked  improvement  being  noticeable  on  the  second  treatment,  which 
was  interrupted  until  the  affected  area  was  entirely  healed.  After  the 
second  treatment,  healthy  granulations  appeared  and  healing  promptly 
followed. 

The  following  case  came  to  me  for  treatment.  The  patient  was  a 
young  man  in  whom  lupus  had  developed  very  slowly  upon  the  side  of 
the  nose,  extending  over  the  bridge  to  the  inner  cauthus  of  the  opposite 
eye.  There  was  no  pain  and  little  or  no  exudation.  Small  nodules 

1  New  York  Medical  Record,  December  24,  1904. 

2  British  Medical  Journal,  June  16,  1903. 
5  Buffalo  Medical  Journal,  January,  1901. 


446  ELECTRO-THERAPEUTICS. 

distinctly  separated  from  oiie  another  were  noticeable  on  palpation. 
Microscopic  examination  of  the  diseased  tissue  confirmed  the  diagnosis. 
After  twelve  treatments  he  was  permanently  cured. 

Dr.  H.  W.  Van  Allen l  reported  fifteen  cases  of  lupus  vulgaris,  with 
80  per  cent,  cures.  The  average  time  since  treatment  was  discontinued 
is  from  one  year  to  eight  months.  The  average  time  of  treatment  is  six 
months,  the  shortest  period  being  three  months,  and  the  longest  nine 
months.  The  most  recent  case  was  treated  three  months  ago.  The 
longest  time  that  has  elapsed  since  treatment  is  three  years.  Eleven 
cases  were  cured ;  in  one  there  was  an  apparent  cure  ;  one  is  returning, 
and  two  cases  were  not  benefited. 

X^vus. 

The  removal  of  hair  from  hairy  naevi  was  successfully  accomplished 
by  Freuud2(iu  his  first  case  of  hypertrichosis  treated  by  this  method) 
and  likewise  by  Pusey.3 

Vascular  Na?vi. — Jutassy4  has  given  a  very  interesting  report  of  the 
successful  treatment  of  an  extensive  vascular  naevus  of  the  face.  Over 
part  of  the  area  involved  the  naevus  was  flat,  but  on  the  cheek  and  nose 
there  were  dilatations  forming  angiomata  from  the  size  of  a  hemp-seed  to 
that  of  a  bean.  The  exposures  were  carried  to  the  point  of  producing  a 
very  acute  dermatitis  with  free  vesication ;  as  a  result  the  growth  was 
practically  destroyed.  There  remained  over  the  area  a  smooth  scar  of 
almost  normal  color.  Xo  trace  of  the  angiomata  remained.  A  year  and 
a  half  later  the  improvement  had  been  maintained. 

Pusey  believes  that  "it  is  possible  that,  by  setting  up  an  acute 
reaction  in  a  vascular  naevus,  there  may  be  produced  scar  tissue  which 
will  be  of  such  a  character  as  practically  to  destroy  the  lesions.  Of 
course,  the  likelihood  of  so  doing  is  greater  the  less  the  dilatation  of  the 
blood-vessels.  It  is  surely  true  that  where  there  are  large  angiomata  the 
method  will  not  be  very  effective,  though  Jutassy's  case  seems  to  show 
that  it  may  be  possible  to  deal  with  superficial  angiomata." 

Lassar,  of  Berlin,  states  that  applications  of  radium  give  better 
results  in  cases  of  naevus  than  do  the  X-rays.  I  am  using  radium  and  the 
X-rays  alternately,  with  apparently  good  results.  At  present  I  am 
treating  a  young  boy  who  has  a  naevus  covering  most  of  one  cheek. 
For  a  control  test,  one-half  the  growth  below  the  eye  is  exposed  to  the 
rays,  the  upper  part  being  shielded  by  lead.  Xo  dermatitis  has  resulted  ; 
the  exposed  area  is  changing  from  a  deep  red  to  a  brownish  hue,  and 
offers  as  a  result  of  lessened  vascularity  a  lighter  color  on  pressure. 

Journal  of  the  American  Medical  Association,  September  15, 1906. 

MVien.  med.  Wochens.,  1897,  xlvii.  p.  428. 

8  Ri'mtgen  Rays  in  Therapeutics  and  Diagnosis,  p.  339. 

4  Pest.  med.  chir.  Presse,  1900,  xxxvi.p.  73,  quoted  by  Pusey. 


THERAPEUTIC  VALUE  IX  DISEASE.  447 

ALOPECIA  AREATA. 

Ullmanu  treated  a  patient  by  two  exposures  of  fifteen  minutes  each, 
on  alternate  days,  the  tube  being  "  medium  soft,"'  at  a  distance  of  15  cm. 
The  hair  in  the  vicinity  fell  out ;  but  at  the  end  of  three  months  it  began 
to  grow,  but  was  of  a  darker  color.  The  treatment  had  evidently  stimu- 
lated both  the  growth  and  pigmentation  of  the  hair,  and  this  result  has 
been  permanent. 

The  treatment  of  alopecia  areata  by  the  X-rays  has  been  reported  by 
Kienbock !  and  Holzknecht.2  Kienbock  reported  a  case  of  a  young  man 
in  whom  the  affection  had  existed  for  three  years.  After  two  months  of 
X-ray  treatment  dark-colored  normal  hairs  appeared,  while  upon  the 
affected  surfaces  the  growth  of  hair  did  not  occur. 

Holzknecht  used  the  method  with  some  success  in  several  cases.  In 
one  case  of  alopecia  areata  that  had  progressed  steadily  for  five  months, 
after  six  months'  treatment  with  the  rays  there  appeared  a  fine  growth 
of  hair. 

Parasitic  Alopecia. — In  alopecia  areata  of  mycotic  origin  it  is  possible 
that  the  X-rays  may  prove  of  use,  and  in  cases  of  tinea  tonsurans  simu- 
lating alopecia  areata  this  treatment  would  probably  be  successful.  That 
X-rays,  however,  cause  temporary  atrophy  of  the  follicles  is  not  a  valid 
reason  for  believing  that  they  would  be  contraindicated  in  alopecia 
areata,  for  unless  a  reaction  is  produced  several  times,  the  healthy  hair- 
follicles  regenerate. 

In  treating  certain  cases  of  epilepsy,  I  observed  in  one  bald-headed 
patient  that  the  application  of  the  rays  was  followed  by  a  growth  of 
short,  stiff  hairs. 

HYPERTRICHOSIS. 

Freund  was  the  first  operator  in  the  field  who  employed  the  X-rays 
in  dermatology  with  success.  He  artificially  produced  an  alopecia  in  a 
case  of  hirsuties.  The  patient  had  previously  undergone  the  usual  course 
of  treatment  when  Freund  experimented  on  the  case  with  the  rays.  In 
the  beginning,  the  field  was  exposed  two  houi'S  each  day,  and  within 
twelve  days  the  hair  commenced  to  fall  out  in  large,  thick  tufts,  and  a 
few  days  later  the  part  was  completely  bald.  This  was  the  first  case  of 
this  kind  cured  by  the  X-rays.  It  is  recommended  that  any  tj'pe  of 
hirsuties  should  be  given  more  numerous  but  less  intense  exposures. 

Jutassy 3  states  that  he  has  employed  the  treatments  as  outlined  by 
Freund  and  Schiff  with  similar  results.  In  the  process  of  epilation  there 
are  four  stages  prominently  defined.  1.  In  the  stage  of  exposure  nothing 
of  any  importance  is  discernible.  2.  During  the  hyperasmic  stage  there 

1  Wien.  klin.  Wochens.,  1900,  xiii.  p.  1053. 

»Ibid.,  1900,  xiii.  p.  1177.  "Orvosi  Hetilap,  1898. 


448  ELECTRO-THERAPEUTICS. 

may  be  a  scattered  or  even  a  complete  shedding  of  the  hair,  but  this  is 
only  temporary,  as  the  hair  roots  are  not  destroyed.  3.  In  the  inflamma- 
tory stage  there  is  an  acute  inflammatory  process,  with  an  accompanying 
slight,  transient  hyperaemia.  Xot  infrequently  this  process  advances  to  a 
pustular  stage,  and  falling  of  the  hair  is  in  many  cases  complete  and  per- 
manent. 4.  Regeneration  of  the  hair  occurs  after  a  period  of  from  two  to 
three  months  and  in  those  insufficiently  treated.  The  absence  of  any 
signs  of  recurrence  after  a  period  of  about  three  months  indicates  that  the 
treatment  has  been  satisfactory,  and  a  prognosis  of  a  permanent  alopecia 
may  be  rendered.  In  one  case  there  was  produced  a  permanent  alopecia 
in  less  than  three  weeks ;  seven  treatments  were  given  with  a  20-minute 
exposure  at  each  sitting. 

Barthe'lemy  and  Oudin1  remark  that  their  conclusions  are  directly 
opposed  to  those  arrived  at  by  Schiff,  Freund,  and  a  number  of  noted 
American  and  English  observers. 

Two  series  of  experiments  were  conducted  on  women,  the  hairy  field 
of  the  pubic  region  being  the  part  selected.  The  hair  of  each  of  the 
patients  presented  dissimilarities  in  color  and  thickness.  In  the  first 
series  the  exposure  was  of  short  duration,  while  in  the  second  series  the 
exposure  was  of  long  duration.  In  the  first  two  cases,  with  exposures  of 
ten  minutes  each,  and  repeated  daily  or  every  other  day  for  a  period  of 
from  two  to  four  weeks,  no  satisfactory  results  were  obtained.  The  third 
case,  frequently  exposed  for  a  long  time,  was  followed  by  an  erythema 
and  a  profuse  shedding  of  hair.  The  exposure  of  the  cases  of  the  second 
series  extended  from  ten  to  thirty  minutes.  The  results  were  negative  in 
three  of  the  cases,  while  in  the  other  three  cases  there  was  only  a  slight 
loss  of  hair,  which  came  out  very  readily  upon  combing  or  by  pulling  upon 
it.  In  only  two  of  the  cases  treated  as  above  was  there  a  complete  falling 
of  the  hair,  one  of  these  cases  being  accompanied  by  a  wide-spread 
erythema. 

Schiff  and  Freund*  reported  that  in  three  cases  a  slight  erythema 
was  the  sole  visible  result  of  the  exposures.  Prior  to  the  falling  out  of 
the  hair,  the  skin  was  visibly  undergoing  the  process  of  bronzing.  The 
pigment  continued  to  accumulate  until  the  hair  fell  out,  followed  by  its 
rapid  disappearance.  Previous  to  shedding,  the  hair  turned  snow-white, 
lost  all  its  pigment,  and  microscopically  exhibited  vacuoles.  In  a  single 
case  this  phenomenon  had  been  repeated  three  times,  when  the  recurring 
dry  hairs  were  again  submitted  to  the  action  of  the  rays. 

Sjogren8  observed  a  rapidly  disappearing  pigmentation  in  a  brunette 
of  25  years  who  was  subjected  to  treatments  similar  to  those  outlined  by 
Schiff  and  Freund. 

1  La  Radiographie,  1900,  xxxix. 

*  Wiener  med.  Wochenschrift,  1898,  xlviii.  p.  1058. 

3  Bibliotheca  medica,  Heft  8. 


THERAPEUTIC  VALUE  IN  DISEASE.  449 

After  the  treatment  all  the  cutaneous  roughness  and  unevenness  dis- 
appear, and  likewise  the  scarring  resulting  from  a  previous  folliculitis. 
The  integument  becomes  smooth  and  free  from  all  blemishes.  Occasion- 
ally there  may  be  noted  a  few  flat,  colorless  depressions,  very  similar  to 
those  following  a  treatment  by  electrolysis.  The  shedding  of  the  hair 
after  a  long  series  of  exposures  would  indicate  accumulative  action  of  the 
X-rays.  Forster1  also  expresses  a  similar  belief. 

Grunmack  has  conducted  experiments  to  ascertain  the  epilatory 
effects  of  the  rays,  but  with  varying  results,  due  to  lack  of  necessary 
precautions. 

I  have  treated  several  female  patients  who  were  disfigured  with 
growths  of  superfluous  hair.  One  woman  presented  a  growth  of  hair  on 
the  neck  and  forearm.  I  treated  the  forearm  first,  to  determine  the 
dosage  and  the  patient's  susceptibility,  and  after  ten  treatments  of  5 
minutes  each,  covering  a  period  of  ten  months,  the  hairs  were  removed, 
without  even  a  vestige  of  erythema.  In  one  patient  the  growth  of  hair 
returned,  but  subsequent  treatment  permanently  eradicated  the  growth. 
This  X-ray  treatment  obviates  the  pain  of  electrolysis. 

FAVUS  AND  TINEA  TONSURANS. 

The  use  of  the  X-rays  in  the  treatment  of  tinea  tonsurans  and  favus 
was  suggested  by  Freund.2  Cases  of  tinea  tonsurans  successfully  treated 
by  the  X-rays  have  been  reported  by  Schiff  and  Freund,*  Torok  and 
Schien,4  and  others.  Cases  of  favus  successfully  treated  have  been 
reported  by  Schiff  and  Freund,5  Hahn  and  Albers-Schonberg,6  Torok 
and  Schien,  Kienbock,  and  others.  One  case  of  Schiff  and  Freund 
has  remained  cured  for  a  year.  In  these  cases  the  reaction  needs  to  be 
carried  to  the  point  of  causing  complete  alopecia  and  slight  cutaneous 
inflammatory  reaction.  Theoretically  the  treatment  is  ideal.  It  causes 
a  falling  out  of  the  diseased  hairs,  at  the  same  time  destroying  the  organ- 
isms upon  which  the  disease  is  dependent.  The  alopecia  which  it  causes 
is  temporary  unless  accompanied  by  a  greater  reaction  in  the  skin  than 
is  necessary. 

The  objections  to  the  method  lie  in  the  fact  that  the  process 
is  a  tedious  one,  and  that  the  exposure  of  a  large  part  of  the  scalp  in 
tinea  tonsurans  or  favus  is  a  procedure  of  some  risk  unless  carried  out 
with  caution.  All  that  is  said  of  the  treatment  of  tinea  tonsurans  applies 
equally  well  to  the  treatment  of  favus. 

1  Wiener  klin.  Wochenschrift,  1897,  No.  3. 
1  Wien.  med.  Wochens.,  1897,  xlvii.  p.  856. 
s  Fortschr.  a.  d.  Geb.  d.  Rontgenstrahlen,  1899,  iii.  p.  109. 
*  Arch.  f.  Derm.  u.  Syph.,  1901,  Ivi.  p.  132. 
5  Wien.  med.  Wochens.,  1902,  Iii.  p.  847. 
6 Munch,  med.  Wochens.,  1900,  xlvii.  pp.  284,  ,".24,  363. 
29 


450  ELECTRO-THERAPEUTICS. 

Batten  '  proved  that  with  X-rays  we  can  make  the  hairs  fall  from  the 
bottom  of  their  follicles,  thus  overcoming  the  difficulty  of  treating  this 
disease.  His  method  of  treatment  is  as  follows  :  A  boy's  ordinary  close- 
fitting  cap  is  covered  on  the  outside  with  a  continuous,  fairly  thick  layer 
of  white  lead,  and  the  latter  with  linen  or  muslin  ;  holes  are  then  cut  in 
this  white-lead  screen  to  correspond  with  all  the  ringworm  patches  to 
be  treated ;  through  these  holes  the  scalp  is  exposed  to  X-rays  from  a 
medium  or  moderately  hard  tube  for  ten  or  eleven  minutes,  six  times 
within  a  fortnight.  The  scalp  should  be  six  to  eight  inches  from  the 
anticathode,  and  the  ears,  neck,  and  face  protected  from  the  rays  by  the 
white-lead  cap  or  similar  shield,  or  by  a  diaphragm  over  the  tube.  Next 
a  simple,  penetrating  parasiticide  lotioii  should  be  applied  morning  and 
night  over  the  whole  scalp,  during  the  period  of  the  treatment.  AVhen 
the  patches  are  quite  bald,  a  mild  parasiticide  ointment  should  be  rubbed 
into  the  scalp  once  a  day,  applying  the  lotion  also  to  the  entire  scalp. 
The  hair  usually  begins  to  grow  within  seven  or  eight  weeks  from  the 
commencement  of  treatment,  and  by  the  end  of  the  third  or  fourth  month 
it  is  fully  grown. 

Adamson  *  states  that,  when  the  X-rays  are  used  for  the  treatment  of 
ringworm  of  the  scalp,  the  hair  of  the  part  exposed  to  the  rays  may  be 
made  to  fall,  leaving  a  smooth,  bald  area,  entirely  free  from  stumps,  and 
when  this  grows  again,  after  an  interval  of  some  weeks,  the  new  hairs  are 
found  to  be  free  from  ringworm.  The  fungus  has  not  been  killed,  but 
has  come  away  with  the  old  hairs,  and  by  the  time  the  new  hair  grows 
not  a  trace  of  it  is  left.  Those  using  this  method  have,  however,  always 
been  chary  of  its  application,  fearing  burns  or  baldness.  But  now,  by 
means  of  Sabouraud's  radiometer,  such  accidents  can  be  readily  avoided. 

The  hair  begins  to  fall  about  fourteen  days  after  the  application,  and 
continues  to  do  so  for  a  few  days  longer.  It  begins  to  grow  again  in  from 
six  to  eight  weeks,  and  is  fully  grown  at  the  end  of  three  months, 
provided  that  the  length  of  exposure  is  not  allowed  to  exceed  the  limit 
set  by  the  right  use  of  the  pastille,  that  no  area  or  part  of  any  surface  is 
exposed  more  than  once,  and  that  the  part  exposed  is  kept  at  the  proper 
fixed  distance  from  the  anticathode  of  the  tube.  By  this  method  there 
is  no  danger  of  permanent  baldness  or  injury  to  the  tissues. 

Concerning  the  value  of  the  X-rays  in  the  treatment  of  tinea,  Sabou- 
raud 3  says  that  ambulant  treatment  is  to  be  recommended,  and  instead  of 
the  two  years  formerly  required,  the  cure  is  complete  in  three  months. 
The  tube  should  be  fifteen  centimetres  from  the  diseased  area,  and  at  the 
same  time  a  scrap  of  platino-cyanide  paper  should  be  exposed  to  the 
centre  of  the  tube  (equal  to  five  Holzknecht's  units),  but  at  a  shorter 

1  Archives  of  the  Rontgen  Ray,  August,  1905. 

1  Lancet,  June  24,  1905. 

s  La  Presse  M6dicale,  Paris,  No.  98,  Dec.  7, 1904. 


THEEAPEUTIO  VALUE  IX  DISEASE.  451 

distance  (eight  centimetres).  "When  the  thin  sensitized  paper  has 
changed  to  the  tint  •'  B''  of  the  radiometer,  the  exposure  is  terminated. 
By  observing  that  the  shade  of  the  sensitized  paper  is  below  the  tint 
"B"  on  five  Holznecht's  units,  the  operator  can  be  confident  that  there 
is  no  danger  of  an  erythema,  burn,  or  permanent  baldness.  After  the 
exposure  the  part  is  treated  with  an  ointment  containing  the  oil  of  cade, 
which  is  washed  off  each  morning.  The  entire  scalp  is  then  rubbed  with 
a  ten  per  cent,  alcoholic  solution  of  tincture  of  iodine,  to  prevent  reinfec- 
tion from  the  hairs  as  they  drop  out  of  the  exposed  patch.  Each  patch 
requires  a  separate  exposure. 

ECZEMA. 

Dr.  R.  Halm  claims  priority  in  radiotherapy  of  eczema,  especially 
the  chronic  type.  At  a  meeting  of  the  Medical  Society  of  Hamburg, 
July,  1898,  he  reported  two  such  cases  that  he  successfully  treated.  Both 
patients  suffered  from  eczema  of  the  thighs  for  periods  of  two  and  four 
years  respectively.  In  the  first  case  a  cure  was  effected  after  twelve 
applications  of  the  rays.  In  the  second  case,  after  four  exposures,  the 
hypercemic  condition  of  the  affected  part  appeared,  followed  by  a  slight 
dermatitis,  which,  however,  disappeared  in  three  days. 

Dr.  Margaret  Sharpe l  reported  a  case  that  affected  a  small  area  of 
the  hand,  following  a  burn,  which  occurred  three  years  previously.  The 
part  had  been  exposed  eleven  times,  each  irradiation  consuming  fifteen  or 
twenty  minutes.  The  lesion  faded  away  gradually,  the  part  appearing 
more  and  more  pallid  as  the  result  of  each  exposure.  There  was  abso- 
lutely no  soreness  or  any  inflammatory  reaction. 

Drs.  Montgomery  and  Orinsby 2  state  that  several  cases  of  chronic 
eczema  treated  by  the  rays  had  given  most  excellent  results.  In  one  case 
of  eczema  which  was  exceedingly  stubborn  and  of  many  years'  standing, 
located  in  the  skin  of  the  scrotum,  in  which  a  vitiliginous  condition  had 
appeared  on  the  infiltrated  skin,  ten  daily  treatments  gave  the  patient 
relief  from  the  itching  ;  the  infiltration  gradually  disappeared,  and  later 
the  normal  pigment  returned. 

Hahn  *  believes  that  if  eczema  is  a  gerin  disease,  then,  as  demon- 
strated by  Rieder,  we  may  expect  the  X-rays  to  influence  the  bacteria 
directly.  If,  on  the  contrary,  it  is  a  nutritional  disease,  the  action  of  the 
rays  in  setting  up  a  dermatitis  leads  us  to  hope  that  the  reactions  of  the 
tissues  will  cause  alterations  in  the  circulation  and  nutrition  with  conse- 
quent healing.  The  point  of  most  interest  is  the  rapidity  with  which  the 
lesions  improved  (usually  after  ten  to  twelve  exposures).  The  effects 
immediately  observed  were  a  decrease  and  in  some  cases  an  absolute 

1  Archives  of  the  Rontgen  Ray,  February,  1900,  p.  5260. 

2  Journal  Amer.  Med.  Assoc. ,  Jan.  3,  1903. 

3  Fortschritte  a.  d.  Geb.  d.  Rontgenstr.,  1901,  1902,  v.  pp.  39-41. 


452  ELECTRO-THERAPEUTICS. 

cessation  of  the  secretion.  In  all  Halm  had  fourteen  cases,  ia  nine  of 
which  he  was  able  to  effect  absolute  cures.  Of  the  remaining  cases  three 
failed  to  materialize  after  three,  four,  and  eight  exposures  respectively  ;  of 
the  other  two  cases,  one  died  of  pneumonia,  and  the  remaining  one  was 
treated  eighteen  times  with  apparently  no  improvement. 

In  cases  of  eczema  I  usually  give  short  and  frequently  repeated 
exposures — i.  e.,  every  other  day — for  the  first  two  or  three  weeks.  After 
this  period  I  expose  the  parts  every  third  or  fourth  day.  By  this  pro- 
cedure I  have  in  some  cases  attained  very  good  results.  For  a  further 
discussion  of  cases  of  eczema  successfully  treated  by  the  rays,  the  reader 
is  referred  to  articles  by  Albers-Schonberg,1  Meek,2  Scholtz,3  Sjogren  and 
Sederholm.* 

ACNE. 

Dr.  R.  R.  Campbell5  reports  fifteen  cases  more  or  less  completely 
cured  by  the  X-rays.  He  used  a  medium  soft  tube,  moderate  illumina- 
tion, about  fifteen  centimetres  from  the  patient,  with  exposures  of  ten 
minutes  each,  usually  every  other  day. 

"MissE.  R.,  age  20,  had  been  under  constitutional  and  local  treatment 
for  three  months,  without  any  appreciable  improvement  in  the  local 
condition.  Early  in  January,  1902,  X-ray  exposures  were  begun.  She 
was  given  three  exposures  weekly  of  ten  minutes  each,  with  the  tube 
fifteen  or  twenty  centimetres  distant.  After  two  weeks  there  was  mani- 
fest improvement,  and  the  exposures  were  reduced  to  two  sittings  weekly  j 
by  the  end  of  February  no  active  lesions  or  comedones  could  be  detected, 
and  the  exposures  were  further  reduced  to  once  weekly  until  the  end  of 
March,  when  all  treatment  was  discontinued.  No  relapse  has  taken 
place.  No  dermatitis  or  erythema  was  produced  in  this  case  at  any  time." 

Altogether  I  have  treated  ten  cases  of  acne.  In  one  patient,  a  girl  of 
nineteen,  whose  face  was  covered  by  the  eruption  of  eighteen  months' 
duration,  I  succeeded  in  completely  curing  the  patient  in  thirty-two  treat- 
ments. These  applications  were  made  three  times  weekly  for  two  weeks 
and  thence  once  weekly.  The  tube  was  fifteen  inches  from  the  face,  three 
inches  spark-gap,  duration  of  each  treatment,  two  minutes.  The  applica- 
tions were  just  stimulating  enough  not  to  produce  an  erythema.  I  do 
not  believe  in  the  production  of  an  erythema  in  the  facial  region.  Seven 
of  the  other  cases  are  apparently  permanently  cured,  and  recurrences 
occurred  in  the  other  two,  after  a  period  of  two  years.  In  one  case  an 
atrophic  condition  of  the  pitted  area  resulted. 

1  Munch,  med.  Wochens.,  1900,  xlvii.  pp.  284,  324,  363. 

1  Boston  Medical  and  Surgical  Journal,  1902,  cxlvii.  p.  152 

s  Arch.  f.  Derm.  u.  Syph.,  1902,  lix.  p.  421. 

*  Fortechrit.  a.  d.  Geb.  d.  Rontgenstr.,  1901,  iv.  p.  145. 

5  Journal  of  the  American  Medical  Association,  August  9, 1902,  p.  343. 


THERAPEUTIC  VALUE  IN  DISEASE.  453 

Acne  Yulgaries. — This  chronic  inflammatory  disease,  which  involves 
the  sebaceous  glands,  usually  appears  in  the  form  of  papules,  tubercles, 
or  pustules,  simple  or  combined,  and  chiefly  affecting  the  head,  face,  and 
neck,  and  occasionally  the  chest. 

Dr.  Joseph  Zeisler1  reports  thirty-four  cases  of  acne  of  different  vari- 
eties and  of  different  degrees  of  severity.  Five  of  these  were  instances 
of  acne  rosacea  and  four  were  indurated  cases  with  pustules  of  the  back 
and  chest. 

"The  bulk  of  them  were,  of  course,  of  the  ordinary  type  of  acne 
of  the  face,  many  of  them  of  the  very  severest  and  most  rebellious  na- 
ture. The  exposures  were  rather  mild  in  character,  the  distance  of  the 
tube,  according  to  its  light,  being  from  twenty  to  forty  centimetres. 

"I  usually  start  in  these  cases  with  three  treatments  a  week  for  from 
two  or  three  weeks.  After  this  exposures  are  given  twice  weekly  only 
for  a  time,  and  later  about  once  a  week.  A  beneficial  action  can  usually 
be  noticed  during  the  second  week,  when  few  new  pustules  are  noted  and 
the  comedones  seem  to  shrink  and  dry  up.  The  accompanying  seborrhosa 
oleosa  of  the  face  is  very  promptly  influenced.  Some  of  the  severest 
cases  which  I  have  ever  treated  were  cured  in  from  four  to  six  weeks, 
and  have  so  far  remained  well." 

A  minimum  reaction  to  the  rays  is  not  always  accompanied  by  the 
cure  of  acne,  but  a  moderate  degree  of  dermatitis  should  be  aimed  at. 
The  disadvantages  of  the  treatment  are  the  pigmentation  liable  to  follow 
in  brunettes,  occasionally  the  slight  cutaneous  atrophy,  and  the  excep- 
tionally severe  dermatitic  reaction.  The  X-rays  cause  the  hairs  to  drop 
out,  and  evidently  check  the  secretion  of  sebum.  The  parenchyma  of 
the  sebaceous  glands  becomes  more  indurated,  and  this  explains  the 
lasting  benefit  derived  in  nearly  every  case  from  X-ray  treatment. 

Dr.  Gautier,2  of  Paris,  reported  sixteen  cases  of  acne  vulgaris  and 
acne  rosacea  which  had  been  successfully  treated  by  X-rays. 

In  hospital  and  private  practice  I  have  had  numerous  cases  of  this 
disease.  In  general  the  results  of  radio-therapy  were  successful  when 
combined  with  other  remedial  measures.  I  have  noted  that  frequent  five- 
minute  exposures  are  more  satisfactory  than  longer  and  less  frequent 
applications.  The  tube  should  be  of  ''medium  vacuum,"  so  that  the 
most  beneficial  results  may  be  obtained. 

Acne  Rosacea. — Jutassy  was  the  first  to  treat  acne  rosacea  by  the 
X-rays.  Hahn 3  reports  two  cases  of  acne  rosacea  in  which  he  obtained 
satisfactory  results.  The  redness  of  the  nose  and  of  the  adjacent  parts 
disappeared,  and  had  not  returned  after  an  interval  of  several  months. 

'Journal  of  the  American  Med.  Asso.,  February-  21,  1903. 

'Compt.-rend.  du  xii.  Congres  international  de  MM.,  Moscow,  vol.  iv.,  August, 
1897,  pp.  385-386. 

'Aerztl.  Verein,  Hamburg,  1900. 


454  ELECTRO-THERAPEUTICS. 

Hyde  and  Montgomery  and  Ormsby '  state  the  following:  "In  a 
few  cases  of  acne  rosacea  our  use  of  the  X-rays  Las  been  followed  by  a 
very  marked  improvement.  In  two  very  extensive  and  very  severe  cases 
of  acne,  which  had  resisted  for  months  all  our  efforts  at  treatment,  the 
eruptive  symptoms  disappeared  completely  under  the  use  of  the  X-rays. 
In  other  cases  a  few  exposures  have  seemed  to  materially  aid  the  other 
treatment  employed. 

"The  cases  of  acne  in  which  radio-therapy  is  of  unquestionable 
value  are  those  in  which  the  disease  is  limited  to  a  small  area.  Here  the 
treatment  may  be  pushed,  if  necessary,  to  the  point  of  producing  atrophy 
of  the  affected  glands  and  follicles.  When  many  scattered  glands  are 
involved  and  new  lesions  are  constantly  forming,  radio-therapy  gives 
temporary  benefit,  but  could  not  be  expected  to  prevent  recurrence  of 
the  lesions  unless  the  treatment  be  carried  far  enough  to  produce  general 
atrophy  of  the  sebaceous  glands  of  the  face.  But  the  sebaceous  glands 
have  a  function  to  perform,  and  to  produce  a  general  atrophy  of  these 
glands  of  the  face  must  be  a  questionable  procedure  until  we  can  deter- 
mine what  effect  such  a  course  would  have  on  the  skin  ten,  twenty,  or 
forty  years  later."  (Figs.  222,  223.) 

SYCOSIS. 

J.  F.  Rinehart  *  speaks  of  the  advantages  of  the  treatment  of  these 
cases  by  the  X-ray.     The  treatment  is  thorough,  painless,  and  there  is 
but  little  scar  tissue  left  after  healing.     He  reports  a  number  of  illustra 
tive  cases,  and  urges  that  too  much  haste  to  obtain  reaction  is  often 
productive  of  marked  inflammation. 

The  treatment  of  sycosis  by  X-rays  was  suggested  and  first  carried 
out  by  Schiff  and  Freund,'  and  there  are  numerous  reports  in  the  litera- 
ture testifying  to  its  success.  Successful  cases  have  been  reported  by 
Hahn,4  Spiegler,5  Rinehart,6  Scholtz,7  Gassman  and  Schenkel,8  Torok 
and  Schein,9  and  others.  The  treatment  has  proved  equally  efficacious  in 
parasitic  and  non-parasitic  sycosis.  In  some  of  the  cases  the  patients 
have  remained  well  a  year  after  the  cessation  of  treatment.  A  typical 
successful  case  of  parasitic  sycosis  is  that  reported  by  Zechmeister.10  In 

1  The  Journal  of  the  American  Medical  Association,  January  3,  1903. 

2  Philadelphia  Med.  Jour.,  1902,  ix.  p.  221. 

s  Wien.  med.  Wochens.,  1897,  xlvii.  p.  856  ;  Fortechr.  a.  d.  Geb.  der  Rontgenstrah- 
len,  1899,  iii.  p.  109. 

*Deut.  med.  Wochens.,  1901,  xxvii.  V.  B.,  p.  29. 
6  Arch.  f.  Derm.  u.  Syph.,  1901,  Ivi.  p.  131. 
•Philada.  Med.  Journal,  1902,  ix.  p.  221. 
'Arch,  f.  Derm.  u.  Syph.,  1902,  lix.  p.  421. 
8Fortschr.  a.  d.  Geb.  d.  Rontgenstrahlen,  1899,  ii.  p.  121. 
•Wien.  med.  Wochens.,  1902,  Iii.  p.  847. 
10Monatsheft  f.  prakt.  Derm.,  1901,  xxxii.  p.  329. 


THERAPEUTIC  VALUE  IX  DISEASE.  455 

this  case  the  face  was  covered  with  deep  follicular  pustules.  Hyphomy- 
cetes  had  been  demonstrated  around  the  roots  of  the  hair.  After  five  strong 
exposures  there  was  a  slight  reddening  and  scaling  of  the  pustules.  Ten 
days  later  the  pustules  had  vanished,  and  in  two  weeks  more  the  disease 
had  entirely  disappeared.  Three  months  later  there  was  no  recurrence. 

Dr.  J.  Zeigler1  reports  very  good  results  with  the  X-rays  in  four 
cases  of  sycosis ;  after  two  or  three  radiations,  pustules  ceased  to  form, 
where  epilation  had  taken  place  new  hairs  began  to  show  after  two 
months,  and  no  relapse  has  since  appeared. 

Schiff  and  Freund  *  speak  of  X-ray  treatment  of  sycosis  as  follows  : 
"When  the  rays  were  applied  seven  times,  complete  recovery  was 
obtained,  leaving  the  skin  smooth  and  free  from  all  inflammatory  con- 
tractions. The  action  of  the  rays  seems  to  be  anti-parasitic,  as  no 
recurrence  had  appeared  after  the  second  month." 

PRURITUS  ANI  AND  PRURITUS  VULV.K. 

Dr.  J.  Rawsoii  Penuington 3  has  treated  several  cases  of  pruritus  ani 
with  the  X-rays.  In  one  case,  after  the  third  treatment  he  began  to 
notice  a  change  for  the  better.  The  exposures  were  continued,  and  the 
tough,  leathery  condition  soon  began  to  disappear.  As  it  passed  away 
the  itching  subsided.  There  has  been  no  itching  for  the  last  four  months, 
and  the  skin  is  normal  to  the  touch. 

In  another  case  the  patient  had  previously  undergone  treatment  for 
hemorrhoids.  Pruritus  followed  the  operation  and  had  been  very 
obstinate  since.  A  few  exposures  to  the  X-rays  eliminated  the  trouble. 

He  also  reported  a  series  of  thirteen  cases  of  pruritus  ani  wherein 
most  of  the  cases  were  cured  by  the  rays  and,  though  still  under  treat- 
ment, all  improved.  The  skin  is  left  smooth,  soft,  clean,  and  pliable. 
While  there  is  no  objection  to  the  use  of  other  procedures  in  conjunction 
with  the  X-rays,  none  was  employed  in  these  cases,  proving  that  the 
successful  results  were  entirely  due  to  radio-therapy. 

Scholtz4  has  seen  improvement  in  a  case  of  pruritus  vulvae,  and 
Sjogren  and  Sederholm 5  have  reported  seven  cases  of  pruritus  vulvse 
which  were  decidedly  relieved  by  this  means. 

XERODERMA  PIGMENTOSUM. 

At  the  Edinburgh  Medico-Chirurgical  Society,  Dr.  Allan  Jameson  6 
exhibited  a  little  girl  suffering  from  xeroderma  pigmentosum  which  had 

1  Journal  of  the  American  Med.  Asso.,  February  21,  1903,  p.  513. 

2  La  Presse  Medicale,  May  27,  1899. 

3  New  York  Medical  Journal  and  Philadelphia  Medical  Journal,  February  20, 1904. 

4  Arch.  f.  Derm.  u.  Syph.,  1902,  lix.  p.  421. 
5Fortsch.  a.  d.  Geb.  d.  Rontgenstr.,  1901,  iv.  p.  135. 

6 Journal  of  the  American  Medical  Association,  February  14,  1903;  Lancet, 
London,  1903.5.  p.  105. 


456  ELECTRO-THERAPEUTICS. 

been  treated  by  the  X-rays.  At  the  age  of  twelve  months  she  began  to 
develop  freckles  at  the  side  of  the  nose.  Later  telangiectases  and  whitish 
spots  appeared  on  her  face.  The  disease  had  extended  to  the  hands  and 
wrists.  When  first  seen,  there  was  an  epitheliomatous  growth  the  size 
of  a  sixpence  on  the  tip  of  the  nose  and  numerous  warty  excrescences 
on  the  face.  Thirty-four  exposures  to  the  rays,  of  five  minutes  each  for 
the  face  and  thirteen  minutes  for  the  right  hand,  were  given.  The  growth 
on  the  nose  and  the  warty  growth  both  disappeared.  The  nose  is  now 
whiter  than  the  rest  of  the  face,  and  there  is  a  marked  improvement  in 
the  right  as  compared  with  the  left  hand. 

PSORIASIS. 

Attempts  to  employ  radio-therapy  in  the  treatment  of  psoriasis  have 
thus  far  given  positive  results  in  the  hands  of  Ziemssen  and  Albers- 
Schonberg.  Jutassy  has  also  made  experiments  in  this  direction,  but  his 
results  are  as  yet  incomplete.  Grouven  and  Hahn  *  have  reported  most 
favorable  results. 

Hyde  and  Montgomery  and  Ormsby8  report  their  experiments  with 
this  disease  as  follows  :  "We  have  treated  thirty-two  cases  of  psoriasis 
with  radio-therapy,  causing  in  each  case  a  temporary  disappearance  of 
the  lesions.  From  four  to  ten  treatments  on  a  given  group  of  lesions  were 
usually  sufficient  to  cause  them  to  disappear  entirely,  except  for  a  certain 
amount  of  pigment.  In  lesions  in  which  the  thickening  was  but  moder- 
ate, the  scales  often  disappeared  after  the  second  or  third  treatment. 
Relief  from  itching,  when  such  is  present,  occurs  about  the  same  time. 

"  In  the  treatment  of  psoriasis  we  use  a  fairly  soft  tube  and  very 
short  exposures,  at  a  distance  of  ten  or  twelve  inches.  It  has  not  been 
necessary  in  any  case  to  produce  any  visible  evidences  of  reaction,  not 
even  in  erythema  or  pigmentation.  The  influence  of  the  rays  on  psoriasis 
is  in  keeping  with  the  fact  demonstrated  by  one  of  us  (Hyde)  twelve 
years  ago,  and  frequently  since,  that  some  psoriatic  patients  can  free 
their  skin  of  all  lesions  by  prolonged  baths." 

F.  S.  Burns 3  states  that  the  treatment  of  this  disease  by  means  of 
the  Rontgen  rays  has  been  thoroughly  tested,  and  no  lesion  has  failed  to 
disappear  under  this  form  of  treatment,  even  though  the  cases  have 
resisted  all  other  forms  of  treatment  for  a  considerable  period  of  time. 
He  bases  his  conclusions  on  a  series  of  150  cases. 

Morris  and  Dore  *  state  that  they  have  seen  good  results  in  chronic 
patches  of  psoriasis.  From  four  to  ten  treatments  were  usually  sufficient, 
in  a  given  group  of  lesions,  to  cause  them  to  disappear  entirely. 

1  Niederrheinische  Gesellschaft  fur  Natur-  und  Heilkunde  in  Bonn,  11,  ii.,  1901. 
1  Journal  of  the  American  Medical  Association,  January  3,  1903,  p.  4. 
1  Boston  Medical  Journal,  October  23,  1903. 
4  British  Med.  Journal,  June  6,  1903. 


FK;.  -JJJ.— Profile  and  full  view  of  a  patient  at  the  Philadelphia  Hospital  with  acne  rosacea. 


FIG.  223.— The  same  after  fifty  irradiations,  which  I  employed  tliri<-«.  weekly.    Distance  of  tube  (soft), 
15  inches  (38  cm.).    Secondary  current  2  ma.,  equivalent  to  No.  2  scale  of  Benoist. 


FIG.  224.— Epithelioma  of  the  nose,  before  irradiation. 


KM;.  ±i->.—  The  same  after  I  irradiated  the  growth  at  the  Philadelphia  Hospital. 


FIG.  226.— Epithelioma  of  1">  years'  standing,  in  which  radium  therapy  was  employed  as  a  control 
test,  by  shielding  half  the  growth  with  lead.  The  protected  half  was  subsequently  treated  with  the 
X-rays.  The  X-ray  treatment  brought  about  a  marked  improvement.  Treatment  with  radium  was 
negative. 


FID.  ±27.— Epithelioma  of  the  dorsum  of 
the  hand,  before  irradiation. 


FII;.  -'is.— The  same  after  irradiation. 


THEKAPEI7TIC  VALUE  IN  DISEASE.  457 

Dr.  E.  S.  Ferris 1  relates  the  following  case  :  Patient,  age  50,  has  had 
psoriasis  as  long  as  he  can  remember.  At  intervals  he  has  undergone 
both  local  and  constitutional  treatment,  the  only  result  of  which  was  an 
apparent  lessening  of  the  scales  for  a  short  time.  Occasionally,  even 
while  under  treatment,  there  was  diminished  activity  manifested  by  dis- 
appearance of  scales  and  a  pallor  of  the  red  patches,  but  the  papules 
never  disappeared.  On  October  1,  1902,  he  presented  himself  for  treat- 
ment. "I  found  the  disease  involved  the  skin  covering  almost  the  entire 
body.  After  trying  various  treatments  and  brush  discharges,  I  gave  him 
sixteen  X-ray  applications  to  his  back  only,  consisting  of  three  expo- 
sures of  ten  minutes  each.  On  the  day  following  the  sixteenth  sitting,  I 
found  the  skin  tender  and  of  a  dusky  hue  ;  later  a  more  marked  reaction 
was  manifested.  After  ten  days  all  traces  of  the  disease  except  slight 
redness  had  disappeared  from  the  part  treated.  Even  this  redness  was 
gone  in  another  week,  and  the  lesion  on  the  chest  vanished  at  the  same 
time.  This  success  encouraged  me  to  apply  the  X-rays  to  the  other 
parts  involved,  with  the  same  happy  results.  At  present  there  is 
absolutely  no  trace  of  the  former  trouble ;  the  skin  is  smooth  and  soft 
and  of  normal  color." 

Drs.  Sjogren  and  Sederholm,  of  Stockholm,2  state  that  two  cases 
of  psoriasis  treated  with  the  X-rays  were  not  in  the  least  benefited 
thereby. 

SENILE  LEG  ULCERS. 

In  1904,  in  the  service  of  Dr.  Ernest  Laplace  at  the  Philadelphia 
Hospital,  I  exposed  twenty  senile  leg  ulcers  to  the  action  of  the  rays. 
The  patients'  ages  varied  from  50  to  65.  Before  treatment  the  ulcers  had 
an  angry  appearance  and  an  offensive  odor,  with  no  granulations.  They 
were  treated  through  sterile  unmedicated  bandages. 

In  most  of  the  cases,  after  several  months'  treatment,  a  slight  der- 
matitis resulted,  and  the  applications  were  discontinued.  The  secretion 
was  checked,  the  odor  disappeared,  and  granulations  began  to  sprout. 
The  areas,  which  previously  had  been  measured  and  photographed, 
showed  a  decrease  in  size.  Three  of  the  patients  are  still  at  the  hospital 
and  are  almost  cured.  Of  the  other  seventeen  some  have  since  died  and 
others  have  disappeared  from  observation. 

VARICOSE  VEINS. 

McGuire 3  reports  two  cases  of  varicose  veins.  The  first  patient  was 
a  woman,  aged  45,  with  eczema  of  both  legs,  complicated  with  varicose 

1  American  Electro- Therapeutic  and  X-Ray  Era,  May,  1903. 
*  Fortschritte  auf  dem  Gebiete  der  Rontgenstrahlen,  June,  1901. 
'Medical  Record,  September  1,  1906. 


458  ELECTRO-THERAPEUTICS. 

veins  and  an  ulceration  on  the  right  leg.  The  ulcer  resisted  all  treatment 
until  the  application  of  the  X-rays.  This  caused  inflammation  of  the 
skin,  which  extended  over  the  whole  surface  of  the  leg.  The  treatment 
was  stopped  for  four  days,  when  it  was  again  tried.  Inflammation 
resulted,  but  during  the  next  five  days,  without  the  application  of  the 
X-rays,  the  dermatitis  gradually  subsided  and  by  the  end  of  the  week  had 
disappeared.  The  ulcer  completely  healed  and  the  varicose  veins  disap- 
peared. The  second  patient  was  a  man,  50  years  of  age,  with  a  large 
bunch  of  varicose  veins  on  the  right  leg.  Treatment  by  the  X-rays  is 
gradually  reducing  the  tumor  and  without  causing  any  great  reaction  of 
the  tissues.  The  rays  cause  contraction  and  atrophy  of  the  tissues  and 
those  of  low  vitality  easily  break  down. 

HYPERIDROSIS. 

Dr.  J.  T.  Dunn1  has  treated  a  number  of  cases  of  hyperidrosis, 
and  asserts  that  it  is  necessary  to  produce  reaction,  by  short  repeated 
treatments,  until  complete  destruction  of  the  sweat  follicles  has 
occurred. 

In  treating  cases  of  hyperidrosis  involving  the  palmar  surface  of 
the  hands,  it  is  necessary  to  be  exceedingly  cautious,  as  the  reaction  is 
usually  easily  produced  and  pain  is  very  severe  in  such  cases.  It  is  his 
experience  that  reaction  appears  after  six  or  eight  treatments  of  ten 
minutes  each  when  applied  to  the  palms  of  the  hands  ;  and  on  account 
of  the  density  of  tissue  involved,  pain  is  severe  if  the  reaction  is 
excessive. 

KRAUROSIS  VULV^:. 

Dr.  G.  H.  Stover1  reports  the  case  of  a  woman,  aged  50,  who  had 
suffered  severely  from  kraurosis  vulva3  for  several  years.  She  was  told 
that  we  knew  nothing  whatever  of  the  effect  of  the  X-ray  in  this 
condition,  and  with  that  understanding  an  exposure  was  made,  a 
tube  of  medium  vacuum  being  employed.  The  exposure  was  made 
at  2  P.  M.  in  March,  1903  ;  that  evening  her  suffering  was  so  great 
that  her  family  physician  was  called.  Some  hours  after  the  raying 
he  found  the  diseased  area  redder  than  common,  swollen  and  osdem- 
atous,  the  appearance  being  much  like  that  of  erysipelas.  Further 
radiation  was  decided  against,  and  after  a  week  or  two,  when  the 
inflammation  had  subsided,  the  affected  tissue  was  excised.  Possibly 
the  rubbing  and  cleansing  which  the  patient  had  given  the  parts  may 
have  had  an  unfavorable  influence. 

1  American  Electro-Therapeutic  and  X-Ray  Era,  December,  1903,  p.  450. 
1  New  York  Medical  Journal,  February,  1904. 


THERAPEUTIC  VALUE  IX  DISEASE.  459 

LEPROSY. 

H.  B.  Wilkinson,1  who  has  had  the  good  fortune  to  study  exten- 
sively the  subject  of  leprosy,  reported  upon  a  series  of  thirteen  cases 
to  the  Manila  Medical  Society,  October  12,  1905. 

He  began  the  treatment  of  leprosy  with  the  X-rays  during  January, 
1904,  with  a  ten-inch  spark  machine,  with  which  he  used  a  bifocal  tube. 
That  portion  of  the  patient  which  presented  the  greatest  amount  of  infil- 
tration was  exposed  to  the  direct  rays  of  the  tube  at  a  distance  of  about 
ten  inches.  The  exposure  lasted  about  ten  minutes  and  was  repeated  at 
intervals  of  several  days.  His  object  was  to  approach  as  near  as  possi- 
ble to  the  burning  point  without  actually  producing  a  burn.  He  called 
particular  attention,  however,  to  the  fact  that  a  cure  resulted  in  the  two 
cases  which  were  accidentally  burned.  After  two  or  three  successive  treat- 
ments, a  blushing  of  the  skin  is  often  observed,  which  is  later  followed 
by  scar  formation.  A  tabulated  statement  of  the  thirteen  cases  treated 
showed  that  three  were  cured,  seven  improved,  and  three  not  improved. 

He  is  inclined  to  believe  that,  when  a  local  lesion  of  leprosy  is  treated 
with  X-rays,  the  organisms  there  localized  are  killed  and  their  bodies 
absorbed  by  the  system,  thereby  producing  an  immunity  against  the 
living  organisms.  This,  as  may  be  seen,  would  be  practically  analogous 
with  the  immunization  of  individuals  against  bubonic  plague  by  injecting 
into  them  killed  cultures  of  plague  organisms.  In  his  cases  he  simply 
grew  the  culture  of  lepra  bacilli  in  the  human  body  as  a  culture  medium 
and  then  killed  them  by  the  use  of  the  X-rays.  In  support  of  this  theory, 
he  cites  the  following  facts  :  1.  The  treatment  of  one  leprous  spot  on  a 
patient  produces  improvement  in  spots  at  a  distance  from  the  one  actually 
treated.  2.  The  cure  in  the  distant  spots  seems  to  progress  parallel  to — 
and  to  be  just  as  complete  as  in — the  one  treated.  3.  The  best  results 
seem  to  be  obtained  only  when  treatment  is  pushed  to  the  point  of  killing 
or  beginning  to  kill  the  tissues,  which  would  also  probably  be  to  the 
point  of  killing  the  organisms.  4.  Cases  in  which  there  are  massive 
localized  leprous  deposits  are  most  rapidly  improved.  There  is  an  abun- 
dance of  culture  on  which  to  operate  and  thereby  produce  immunity 
more  rapidly.  5.  In  diffuse  general  involvement  of  slight  degree  or 
atrophic  character,  where  there  are  only  a  few  scattered  organisms,  little 
success  is  to  be  expected. 

Sequeira  *  reports  a  nodulated  form  of  leprosy  of  the  skin  which  has 
shown  marked  improvement ;  the  hard  masses  became  soft  and  flat. 

Scholtz3  treated  two  cases  of  leprosy  with  X-rays  without  results; 
de  la  Camp  also  obtained  negative  results. 

114  Some  Observations  on  Leprosy  in  the  Philippine  Islands,  with  an  Account  of 
its  Treatment  with  the  X-ray,"  Medical  Record,  December  9,  1905,  reported  by  a 
special  correspondent  at  Manila. 

*  British  Medical  Journal,  September  28,  1901,  p.  851. 

3  Arch.  f.  Dei-mat,  u.  Syphilis,  vol.  lix.,  1902,  pp.  443-444. 


460  ELECTRO-THEKAPEUTICS. 

II.   Malignant  Growths. 
A.  EPITHELIOMA. 

lu  the  X-ray  treatment  of  epitheliomata  a  number  of  circumstances 
must  be  considered, — the  rapidity  of  the  growth,  its  character,  location, 
and  glandular  involvement,  age  of  the  patient,  and  the  state  of  health. 

When  the  epithelioma  has  grown  rapidly,  I  advise  an  immediate 
operation  and  subsequent  X-ray  treatment.  In  cases  of  slow  growth  I 
am  in  favor  of  X-ray  treatment  only.  (Figs.  224,  225,  and  226.)  The 
severity  of  an  epitheliomatous  growth  is  largely  dependent  on  the  proxim- 
ity of  the  lymphatic  chain  of  glands.  Thus,  such  an  ulcer  of  the  upper  lip 
is  far  less  likely  to  produce  metastases  than  one  of  the  lower  lip,  and  con- 
sequently irradiation  of  the  former  will  yield  the  better  results.  Likewise 
the  anterior  portion  of  the  tongue  aifords  better  results  in  treatment  than 
the  posterior  part.  Again  it  is  easier  to  irradiate  the  external  than  the 
internal  canthus  of  the  eye,  because  of  the  excess  of  lachrymation  pro- 
duced when  the  latter  is  treated.  In  making  a  prognosis  it  is  essential 
to  differentiate  between  the  forms  of  epithelioma  very  carefully,  since 
these  neoplasms  vary  in  their  malignancy  according  to  their  locality  and 
the  depth  of  the  tissues  involved. 

The  results  obtained  in  the  treatment  of  epitheliomata  by  the  Ront- 
gen  rays  have  more  than  satisfied  its  most  sanguine  advocates.  That 
these  malignant  cutaneous  growths  can  be  made  to  disappear  entirely  has 
been  the  common  experience  of  Eontgen  therapeutists. 

Carl  Beck,  of  New  York,1  and  others  make  a  statement  which  is 
slightly  at  variance  with  the  views  of  certain  noted  investigators  in  this 
line.  They  deem  it  essential  to  remove  surgically  all  such  diseased  areas. 
This  they  regard  as  the  most  valuable  form  of  treatment ;  notwithstand- 
ing this  fact,  they  assert  that  it  is  proper  to  employ  the  rays  after  the 
gro\vth  has  been  excised.  It  is  my  belief,  and  which  I  have  abundantly 
confirmed,  that  the  X-rays  should  be  applied  without  any  surgical 
intervention. 

W.  Merrill  and  W.  Johnson2  were  the  first  in  this  country  to  report 
the  results  obtained  in  malignant  diseases  by  treatment  with  the  X-rays. 
Their  first  case,  one  of  cutaneous  cancer  of  small  dimensions,  was  cured 
in  October,  1899.  The  discharge  soon  ceased,  pain  was  relieved,  and  in 
general  the  result  was  satisfactory. 

Another  case  reported  was  an  epithelioma  affecting  principally  the 
nose  and  involving  the  nasal  septum.  The  case  was  carefully  watched, 
and  one  year  later  no  apparent  sign  of  recurrence  was  demonstrable. 

In  the  third  patient  the  cutaneous  cancer  affected  the  lower  part  of 
the  bridge  and  tip  of  the  nose.  The  treatment  was  the  same  as  was 

1  Medical  Record,  February  7,  1902. 

1  Philadelphia  Medical  Journal,  December  8,  1900,  vi.  p.  1089. 


THERAPEUTIC  VALUE  IN  DISEASE.  461 

applied  in  the  other  two  cases,  except  that  the  exposures  were  shorter 
in  duration  and  more  frequent.  After  an  interval  of  three  years  the 
patient  has  no  sign  of  a  recurrence. 

They  also  reported  sixteen  additional  cases l  regardless  of  their  length 
of  existence,  extent  of  tissue  involved,  and  previous  treatment  received  ; 
ten  patients,  or  62.5  per  cent.,  are  apparently  cured  ;  four  other  cases,  or 
25  per  cent.,  show  improvement,  and  three  of  these  give  promise  of 
ultimate  recovery  under  further  treatment. 

Sjogren 2  states  that  in  nearly  all  his  cases  of  epithelioniata  treated 
by  means  of  the  rays,  a  change  for  the  better  might  be  observed  even 
though  apparently  no  inflammatory  reaction  developed.  He  seems  to  be 
convinced  that  in  order  to  bring  about  an  absolute  cure  one  must  set  up 
an  inflammatory  reaction  of  intense  severity.  This  causes  a  degenera- 
tion of  all  (or  at  least  the  majority)  of  the  embryonic  cellular  elements, 
which  is  the  aim. 

Wni.  Sweet,  of  this  city,3  reports  most  satisfactory  results  obtained 
from  his  treatments  in  three  cases  of  epithelioniata  involving  the  tissues 
surrounding  the  eyeball. 

William  Allen  Pusey 4  reports  having  treated  several  cases  of  epi- 
thelioma,  in  which  there  was  no  involvement  of  the  deeper  orbital  tissues, 
and  all  resulted  in  cures  where  sufficient  treatment  was  permitted.  No 
relapses  have  occurred,  and  some  of  the  cases  were  treated  about  three 
years  ago. 

"Win.  M.  Sweet 5  believes  that  it  is  no  longer  right  to  resort  to  plastic 
operations  in  cases  of  epithelioma  in  ocular  affections,  basing  his  judg- 
ment on  the  successful  results  of  eighteen  out  of  twenty  cases  treated. 

Allen6  treated  five  cases  of  Jacob's  or  rodent  ulcer,  which  were 
entirely  cured  by  the  application  of  the  X-rays.  Two  of  these  involved 
the  lower  eyelids,  two  the  nose,  and  one  the  centre  of  the  cheek.  All 
these  were  of  long  standing  and  very  slow  development :  one  of  them,  at 
the  side  of  the  nose,  had  been  developing  for  fifteen  years.  When  once 
cured  by  the  X-rays,  these  lesions  seldom  recur. 

De  Schweinitz 7  has  had  four  cases  of  "entire  and  rapid  cicatriza- 
tion," with  no  relapse.  In  two  additional  cases  the  results  were  entirely 
negative,  or  possibly  the  condition  was  aggravated.  In  one  of  the  latter, 
excision  was  practised  with  subsequent  application  of  the  rays,  without 

1  American  Medicine,  August  9,  1902. 

1  Fortschritt.  a.  d.  Geb.  d.  Rontgenstrahlen,  1901. 

3  American  Medicine,  December  13,  1902. 

4  Chicago  Medical  Reporter,  April,  1902. 

5  Medicine,  April,  1904. 
•Trans.  Amer.  Derm.  Asso.,  1903. 

T  Personal  statements  made  to  Dr.  G.  Oram  King  and  embodied  in  an  article, 
"The  Value  of  X-rays  in  Ocular  Therapeutics,"  Journal  of  the  American  Medical 
Association,  September  29,  1906. 


462  ELECTRO-THERAPEUTICS. 

recurrence.  De  Schweinitz  concludes  the  rays  should  be  tried  for  a  cer- 
tain period,  and,  if  the  results  are  not  good,  then  excision  with  or  without 
plastic  operation  should  be  practised. 

Charles  Lester  Leonard,1  whose  experience  has  been  extensive  in 
treatment  of  epitheliomas  and  various  skin  lesions  involving  the  eyelids, 
regards  it  as  uniformly  and  permanently  successful.  Baker 2  writes  that 
he  has  had  five  cases  of  rodent  ulcer,  with  perfect  recovery.  One  case 
of  special  interest  had  been  under  observation  for  ten  years ;  all  this 
time  the  disease  was  slowly  progressive  ;  not  only  the  eye,  but  the  cheek 
and  temple  were  involved.  The  eye  was  enucleated  and,  later,  X-ray 
applications  were  made  for  a  year  or  more  less  regularly,  resulting  in 
complete  cicatrization,  with  no  evidence  of  recurrence  at  the  end  of  four 
years.  In  a  sixth  severe  case,  in  which  both  X-rays  and  radium  were 
used,  a  complete  cure  has  been  effected,  the  curative  agent  being,  in 
Baker's  judgment,  the  Rontgen  rays.  In  eight  cases  of  epithelioina  the 
results  have  been  entirely  satisfactory,  although  in  most  of  the  cases  the 
knife  was  used  and  followed  by  the  X-rays.  There  have  been  no  recur- 
rences. Baker  had  two  cases  of  lupus  involving  the  eyelids,  that  have 
been  "very  greatly  improved  if  not  entirely  cured  by  the  X-rays." 

Hermann  Knapp*  has  seen  "four  temporary  results  in  epithelionia 
and  the  like."  Stevenson 4  has  used  the  X-rays  with  success  in  treatment 
of  lupus  of  the  eyelids  only.  Xewcomet5  advises  me  that  he  has  treated 
about  thirty  cases,  few  of  which  have  shown  any  disposition  to  recur. 

The  names  of  a  host  of  foreign  and  home  workers  in  ophtha.1  mo- 
logic  lines  or  electrotherapy  could  be  added  if  additional  testimony 
were  needed. 

J.  F.  Schamberg6  treated  a  case  of  marked  interest, — an  epithelioma 
involving  not  only  the  lids,  but  the  conjunctiva  as  well.  A  perfect  cure 
was  effected,  and  after  two  years  Schamberg  reports  no  recurrence. 

Drs.  Hyde,  Montgomery,  and  Ormsby7  have  been  very  successful 
in  treating  fifty-five  cases  of  epithelioma ;  in  a  number  of  the  cases 
the  major  part  of  the  growth  disappeared,  in  twenty-five  cases  the 
lesions  have  been  entirely  replaced  by  scar  tissue,  and  there  has  been 
no  evidence  of  recurrence  during  periods  varying  from  two  to  nine 
months. 

In  surface  carcinoma  involving  deeper  tissue  their  results  have  not 
been  uniformly  satisfactory. 

Dr.  W.  B.  Coley8  reports  that  out  of  forty-four  cases  of  epithelioma 
of  the  various  regions  of  the  face  and  head  only  four  cases  were  cured. 

'Personal  statements  made  to  Dr.  G.  Oram  King  and  embodied  in  an  article, 
"The  Value  of  X-rays  in  Ocular  Therapeutics,"  Journal  of  the  American  Medical 
Association,  September  29, 1906. 

2  Ibid.  "Ibid.  4  Ibid.  5Ibid.  6Ibid. 

7  Journal  of  the  American  Medical  Association,  January  3,  1903. 

8  Annals  of  Surgery,  August,  1905. 


THERAPEUTIC  VALUE  IX  DISEASE.  4G3 

Dr.  A.  D.  Rockwell1  treated  two  cases  of  epithelionia,  giving 
forty  five  and  forty-seven  exposures  respectively  ;  recovery  occurred  in 
both  cases. 

Dr.  G.  G.  Burdick2  reports  80  cases  of  epithelioma,  involving  the 
skin  only,  treated  by  the  X-rays.  There  were  no  recurrences.  In  cases 
of  epithelioma  situated  at  the  muco-cutaueous  junctions,  he  advises 
removal  of  the  glands  in  the  vicinity.  After  an  interval  of  two  years, 
this  method  was  in  23  cases  followed  by  no  recurrence. 

Dr.  Chas.  L.  Leonard3  reported  a  case  of  epithelionia  of  twelve 
years'  standing,  which  has  remained  healed  for  two  years. 

Dr.  Russel  H.  Boggs4  treated  12  cases  of  primary  epithelioma ;  9  of 
them  were  apparently  cured,  1  almost  cured,  2  very  little  improved. 

Dr.  G.  P.  Girdwood 5  reports  8  cases  of  typical  rodent  ulcer ;  4  of 
them  completely  healed  and  the  other  4  did  not.  He  treated  all  with  the 
same  apparatus  and  technic.  He  asks,  "Is  it  simply  the  difference  of 
constitution,  or  is  there  some  difference  which  the  microscope  does  not 
reveal  that  should  make  so  great  a  difference  in  the  result?" 

I  have  had  similar  failures,  and  am  of  the  opinion  that  previous 
surgical  treatment  and  the  special  location  of  the  growth  are  important 
governing  factors.  French  pathologists  believe  that  different  epitheliomas 
present  different  histological  characteristics. 

In  the  above  reports  we  notice  a  great  diversity  of  opinion.  Some 
prefer  the  soft  and  others  the  hard  tube.  Views  also  vary  as  to  the  dura- 
tion of  the  seances  and  their  frequency.  It  is  asserted  by  some  that  a 
slight  dermatitis  is  always  to  be  aimed  at,  in  order  to  obtain  the  proper 
action.  The  great  variety  of  cases  encountered  will  allow  of  no  special 
technic  ;  the  peculiarities  of  the  epitheliomas  themselves  will  frequently 
dictate  the  method  to  be  pursued. 

Sequeira.6  who  treated  45  cases  of  rodent  ulcer  since  June,  1901, 
states  that  the  ulcers  healed  rapidly  and  large  cavities  filled  up,  but  that 
he  had  had  difficulty  with  the  hard,  raised  edges.  He  also  observed 
slight  recurrences. 

He  likewise  reported  83  cases  of  rodent  ulcer,  34  of  which  were 
healed,  and  the  majority  of  the  remainder  were  still  under  treatment. 
He  found  that  when  cartilages  of  the  nose  and  bones  were  involved, 
the  condition  was  unfavorable. 

He  observed,  microscopically,  a  destruction  of  the  epithelial  cells, 
and  in  some  of  them  a  fatty  change  occurred  and  the  connective-tissue 
elements  were  also  stimulated,  and  this  stimulation  caused  the  filling  of 

1  New  York  Med.  Journal,  April  7,  1906. 

1  Transactions  of  the  American  Rontgen  Ray  Society,  1905. 

s  Ibid. 

4  Ibid. 

5  Transactions  of  the  American  Rontgen  Ray  Society,  1906. 

6  British  Medical  Journal,  September  28,  1901. 


ELECTRO-THERAPEUTICS. 

cavities  and  the  formation  of  healthy  scar  tissue.  He  also  recommends 
the  use  of  the  actual  cautery  when  there  is  difficulty  in  causing  the  hard 
edge  of  the  growth  to  disappear. 

Joseph  T.,  aged  63,  with  a  negative  family  history,  presented  an 
epithelioma  of  the  dorsum  of  the  hand  the  size  of  a  half-dollar.  (Figs. 
227,  228.)  Two  months  before, — i.e.,  in  October,  1902, — after  two  years 
of  apparent  cure,  the  lesion  became  painful,  ulcerated,  and  began  to 
spread.  The  trouble  began  twelve  years  ago,  with  a  small  papule  on  the 
back  of  the  right  hand.  This  grew  steadily  and  slowly,  and  defied  local 
measures.  Patient  was  subjected  to  X-ray  irradiation,  and  about  two 
and  a  half  or  three  years  later  I  reported  the  lesion  healed,  but  it  subse- 
quently reappeared,  and  at  the  beginning  of  the  last  treatment  the  ulcer- 
ation  had  reached  the  size  of  a  fifty -cent  piece.  Surface  appears  clean, 
devoid  of  granulations,  with  rough  and  thickened  edges.  After  thirty 
irradiations  the  patient  improved,  but  slight  dermatitis  forbade  further 
treatment.  Subsequently  the  growth  was  again  irradiated,  and,  at  the 
expiration  of  sixty  treatments  in  all,  the  patient  made  a  perfect  recovery. 

The  technic  that  I  usually  employ  is  to  irradiate  thrice  weekly  for 
three  weeks,  duration  of  each  stance  about  eight  minutes.  Crookes 
(soft)  tube,  10  to  12  inches  (25  to  30  cm.)  distance. 

B.  CARCINOMA. 

The  results  sought  for  in  X-ray  treatment  of  carcinoma  depend  upon 
several  factors : 

Depth  and  rapidity  of  growth,  age  and  health  of  the  patient,  and 
technic  employed. 

The  deeper  the  growth  the  fewer  the  rays  that  will  reach  the  cancer- 
ous part,  most  of  the  rays  being  absorbed  by  the  skin.  We  cannot  push 
the  treatment  as  we  should  desire,  for  to  do  so  would  be  to  cause  a 
dermatitis  that  would  eventuate  in  gangrene  and  necrosis. 

In  cancers  of  rapid  growth  the  knife  should  precede  irradiation. 
To  do  otherwise  is  to  sacrifice  needed  radical  treatment  arid  perhaps  life. 

After  operation  I  advise  irradiations  through  the  dressings,  in  order 
to  destroy  the  cancer  cells  left  by  the  surgeon.  If  small  subcutaneous 
nodules  should  appear  four  or  more  months  after  the  operation,  they 
should  be  irradiated.  I  have  seen  very  many  of  these  nodules  com- 
pletely removed  by  this  means.  Of  course  the  younger  and  the  more 
robust  the  patient,  the  better  will  be  the  results  of  treatment. 

I  cannot  agree  with  those  physicians  and  pathologists  who  assert  that 
the  X-rays  hasten  cancerous  inetastases ;  their  statement,  that  the  rapid 
disintegration  of  the  cancer-cells  (that  cannot  be  eliminated  by  natural 
means)  must  invade  surrounding  tissue,  I  believe  to  be  faulty. 

Reports  of  X-ray  therapeutists  are  widely  divergent  as  to  the  value 
of  X-rays  in  the  treatment  of  cancer.  I  believe  that  this  is  largely  due 


THERAPEUTIC  VALUE  IX  DISEASE.  465 

to  the  use  of  inefficient  apparatus  aud  to  errors  in  diagnosis  (benign 
growths  being  mistaken  for  malignant  ones),  which  point  to  the  impera- 
tive necessity  of  examining  microscopically,  before,  during,  and  after 
irradiation,  sections  or  scrapings  of  the  growth. 

The  vacuum  of  the  tube  is  a  matter  of  prime  importance,  especially 
in  treating  the  deeper-seated  cancers  ; — i.e.,  the  vacuum  should  be  high  in 
order  to  allow  of  a  deeper  penetration.  In  the  body  cavities, — as  the 
mouth,  rectum,  vagina,  etc., — I  believe  in  the  direct  application  of  the 
rays,  and  not  by  special  cavity  tubes. 

Probably  we  err  too  much  on  the  side  of  safety  ;  apparently  the 
stances  are  too  brief,  we  too  often  fearing  the  production  of  a  severe  type 
of  dermatitis.  An  erythema  or  slight  dermatitis  is  unavoidable;  per 
contra,  it  is  advisable  as  indicating  the  particular  individual  tolerance. 
I  do  not  endorse  the  Continental  method  of  massive  single  doses,  but  in 
common  with  our  own  operators,  I  strongly  advise  and  always  use  short 
and  frequently  repeated  exposures. 

I  do  not  confine  treatment  to  the  involved  area,  as  the  disease  may 
have  invaded  surrounding  territory.  Thus,  in  treating  a  mammary 
carcinoma  I  irradiate  the  axillary  and  subclavian  glands  on  the  diseased 
side  and  also  the  opposite  breast.  This  applies  to  cancer  of  the  tongue, 
with  its  associated  cervical  lymphatics,  etc. 

Cancer  of  the  Breast. — Perhaps,  as  far  as  violent  malignant  disease  is 
concerned,  cancer  of  the  breast  is  more  favorably  influenced  by  the 
X-rays  than  the  same  disease  occurring  in  any  other  part  of  the  body. 

Personally,  I  have  encountered  quite  a  large  number  of  cases  of 
carcinoma  in  various  regions.  The  results  obtained  varied  considerably. 
Some  of  the  cases  showed  absolutely  no  effects  under  the  most  persistent 
treatment,  others  showed  slight  improvement,  while  in  only  four  cases  of 
mammary  carcinoma  I  succeeded  in  bringing  about  changes  for  the  better 
which  might  be  designated  absolute  cures.  I  shall  report  only  the  cases 
which  gave  very  good  results. 

CASE  I. — A  woman,  aged  34,  had  rapidly  developed  a  carcinoma  of 
the  left  mammary  gland.  She  readily  consented  to  undergo  an  operation. 
Upon  palpation  we  could  not  discover  any  enlargement  of  the  axillary 
glands.  The  patient's  wound  granulated  rapidly,  so  that  it  was  appar- 
ently healed  in  the  course  of  four  weeks.  The  pathologist  diagnosed  the 
malignant  portion  as  an  adeno-carcinoma.  Two  months  after  the  opera- 
tion three  small  nodular  masses  developed  within  the  old  scar ;  they 
increased  in  size  and  ultimately  ulcerated.  The  patient  was  advised  to 
undergo  X-ray  treatment.  She  was  brought  to  me  three  months  after 
operation.  I  exposed  the  diseased  area  once  daily  for  one  week,  in- 
ducing by  these  frequent  applications  intense  inflammation,  and  from 
general  appearances  the  area  was  growing  rapidly  worse.  The  exposures 
lasted  for  eight  minutes  each,  the  tube  being  twelve  inches  (30  cm.) 
distant.  The  second  week  all  treatments  were  discontinued.  I  started  on 
so 


466  ELECTEO-THEEAPEUTICS. 

the  third  week  giving  a  six-minute  exposure  every  third  day,  the  tube 
being  fourteen  inches  distant  in  the  beginning,  and  gradually  brought 
down  to  eight  inches  (20  cm.)?  until  the  last  exposure  had  been  given. 
The  wound  had  been  treated  sixteen  times  before  we  were  able  to  note 
any  changes.  These  changes  were  a  lessening  of  the  discharge  and  the 
formation  of  a  scab  from  the  drying  exudate.  The  patient  suffered  abso- 
lutely no  pain  in  the  beginning  of  the  treatments,  but  about  three  weeks 
subsequently  she  experienced  most  excruciating  agony.  This  would 
lessen  considerably  after  each  treatment,  and  again  become  worse,  when 
it  would  subsequently  be  relieved,  and  so  on.  When  the  discharge  had 
all  discontinued,  the  pain  almost  entirely  subsided.  The  ulcers  seemed 
to  be  healing  at  the  edges  and  the  intense  induration  present  also  gradu- 
ally disappeared.  In  all  I  gave  forty-five  treatments  and  effected  a  cure. 
I  have  watched  the  patient  for  nearly  sixteen  months,  and  up  to  the 
present  time  no  signs  of  recurrence  have  been  noticed. 

CASE  II. — The  patient  was  a  woman  of  62,  from  whom  carcinoma 
of  the  breast  had  been  removed.  On  operation  no  tuberculous  glands 
could  be  detected.  Six  weeks  after  operation,  before  the  wound  had 
fully  healed,  the  disease  recurred,  near  the  seat  of  the  former  nipple. 
The  patient  received  in  all  thirty-three  treatments  ;  irradiation  was  given 
every  fourth  day,  lasting  six  minutes.  The  disease  has  not  recurred  now 
for  eleven  months. 

CASE  III. — A  multiple  carcinoma  occurring  in  a  woman  63  years  of 
age,  affecting  the  breast.  The  involvement  had  not  been  extensive, 
though  sufficient  to  cause  alarm.  The  tissue  between  the  ulcerated 
nodules  was  normal,  though  the  skin  was  slightly  inflamed.  The  patient 
had  an  epithelioma  of  the  lip,  fourteen  or  fifteen  years  before,  operated 
on,  with  no  signs  of  recurrence.  The  patient  had  been  actively  treated 
for  four  months,  and  occasionally  for  the  four  succeeding  months.  At 
first  the  treatments  were  given  every  fourth  day,  each  one  lasting  from 
three  to  eight  minutes.  By  the  end  of  the  first  four  mouths  the  carcinoni- 
atous  field  had  entirely  disappeared,  leaving  small  scars  very  difficult 
of  detection. 

CASE  IV. — Mrs.  B. ,  carcinoma  of  the  right  breast.  She  was  operated 
upon  by  Dr.  M.  P.  Warmuth,  on  September  29,  1903,  and  X-ray  treat- 
ment was  instituted  January  1,  1904.  I  gave  her  twenty-five  treatments, 
thrice  weekly.  Up  to  the  present  time  there  has  been  no  recurrence. 

CASE  V. — Miss  J.  L.,  age  24,  a  nurse,  with  cancer  of  right  breast ; 
her  mother  died  of  mammary  carcinoma.  Dr.  Warmuth  operated  in 
November,  1904,  and  I  instituted  X-ray  treatment  in  January,  1905.  In 
the  meanwhile  she  married.  On  October  10,  1905,  she  noticed  a  swelling 
on  the  left  breast.  I  gave  her  ten  treatments  before  the  operation  and 
subsequently  the  left  breast  was  also  removed.  Post-operative  tn-at 
ment  was  given  for  a  period  of  three  weeks.  She  is  now  in  good  health. 

CAKE  VI. — Mrs.  C.,  was  operated  upon  by  Dr.  John  B.  Deaver,  on 


THERAPEUTIC  VALUE  IN  DISEASE.  467 

November  27,  1905,  for  cancer  of  the  right  breast,  and  referred  to  me  by 
Dr.  Taylor.  I  began  X-ray  treatment  one  month  after  the  operation,  and 
gave  her  three  exposures  weekly  for  three  months,  duration  ten  minutes. 
Anodal  distance  ten  inches.  Both  breasts  and  axillary  regions  were 
irradiated.  At  present  I  treat  her  once  monthly.  She  is  perfectly  well 
and  there  is  no  sign  or  symptom  of  a  recurrence. 

CASE  VII. — Mary  Moore,  age  51,  single,  housewife.  Family  history 
negative.  Duration  of  the  present  disease  ten  months  (secondary). 
The  trouble  began  as  a  small  white  papule  under  the  left  axilla.  Three 
months  later  the  patient  was  operated  upon  for  the  growth,  which  had 
increased  greatly  in  size  and  extent ;  surgical  measures  were  only  partly 
successful.  The  patient  was  treated  for  three  months,  thrice  weekly. 
Eventually  the  part  healed,  but  the  patient  died  from  metastatic 
involvement. 

CASE  VIII. — Kate  Quiun,  age  61,  married,  housewife.  She  was  run 
down  by  a  bicycle  eleven  years  before  coming  to  me,  and  a  year  later 
there  appeared  over  the  site  of  the  trauraatism  a  small  growth,  that 
increased  in  size  until  it  involved  nearly  all  of  the  right  breast ;  ulcer- 
ation  occurred  and  spread  rapidly.  There  was  no  apparent  involve- 
ment of  the  adjacent  lymphatics.  Treatment  was  instituted  June  22, 
1904 ;  forty-five  exposures  were  given,  each  of  ten  minutes  duration. 
The  pain,  discharge,  etc.,  disappeared,  but  four  months  later  the  patient 
expired.  Death  was  due  to  general  infection. 

II.  Gocht 1  reported  two  cases  of  carcinoma  of  the  breast  exposed  to 
the  influence  of  the  rays.  Both  of  these  cases  had  been  regarded  as 
inoperable.  No  cures,  however,  were  effected,  though  in  one  of  the  cases 
pain  was  almost  entirely  relieved.  The  other  case  died  before  any 
improvement  had  been  discerned. 

George  G.  Hopkins2  reported  two  cases  of  carcinoma  of  the  mam- 
mary glands  treated  by  the  rays.  The  first  case  was  entirely  cured  after 
thirty-two  treatments  had  been  given.  The  second  case  only  showed 
improvements,  such  as  lessening  of  discharge  and  pain  and  partial 
healing  of  the  ulcer. 

Ayers 3  also  reported  the  results  obtained  in  two  cases  of  mammary 
carcinoma.  The  first  had  been  operated  on,  and,  before  healing  had  been 
completed,  areas  of  recurrence  of  the  disease  were  noticeable.  These 
areas  were  exposed  daily  for  four  minutes  during  three  and  a  half 
months.  Healing  was  absolutely  complete,  with  no  symptoms.  The 
second  case  had  a  great  deal  of  induration,  ulcerating  at  three  areas.  The 
axilla  had  also  been  much  involved.  The  results  obtained  were  a 
decrease  in  size  of  the  induration,  considerable  lessening  of  the  ulcerating 
discharge,  and  the  disappearance  of  all  pain. 

1  Fortschr.  a.  d.  Geb.  d.  Rontgenstrahlen,  1897,  i.  p.  14. 

'Philadelphia  Medical  Journal,  1901,  viii.  p.  404. 

5  The  Kansas  City  Medical  Index-Lancet,  1902,  xxiii.  p.  18. 


468  ELECTRO-THERAPEUTICS. 

Chisholm  Williams1  reports  a  woman,  42  years  old,  single,  having  a 
scirrhous  form  of  recurrent  ulcerative  carcinoma  of  the  breast  treated  by 
X-rays,  twice  a  week,  five  minutes  each  sitting;  in  all  28  exposures 
were  given.  There  has  been  no  recurrence  during  the  past  four  and  a 
half  years,  and  the  patient  is  still  in  excellent  health.  He  also  reports 
a  similar  case  in  which  lumps  in  the  axillary  region  disappeared  and 
remained  cured  for  three  years. 

Dr.  S.  M.  McCollin1  reports  a  recurrent  carcinoma  of  the  breast 
with  an  ulcerated  surface  five  by  eight  inches.  The  patient  was  relieved 
of  all  pain,  skin  formed  over  the  ulcer,  and  life  was  prolonged  for  nearly 
one  year. 

Dr.  G.  H.  Stover*  says  that  in  his  own  experience  prophylactic 
treatment  has  resulted  in  failure.  He  believes  that  this  may  be  due  to 
the  treatment  not  being  sufficiently  vigorous  or  continued  long  enough. 
He  thinks  anti-operative  treatment  is  of  benefit.  Kor  is  Stover  alone  in 
this  view,  a  number  of  skiagraphers  sharing  the  same  opinion. 

Dr.  R.  H.  Boggs  *  observed  23  cases  of  carcinoma  of  the  breast ;  15 
of  these  patients  were  operated  upon  and  a  recurrence  had  taken  place 
when  they  came  for  X-ray  treatment.  Up  to  the  present  time,  8  patients 
have  died,  2  have  been  lost  sight  of,  and  the  other  13  are  living ;  7  of 
these  are  apparently  cured,  2  are  under  treatment,  and  the  other  4  are 
gradually  becoming  weaker.  Some  of  them  were  treated  three  years  ago, 
but,  of  course,  this  is  still  too  short  a  time  to  say  that  there  will  be  no 
recurrence. 

Dr.  Joseph  F.  Smith5  says  that  in  carcinoma  of  the  breast  he  has 
seen  small  recurrences  along  the  line  of  incision  or  small  nodular  involve- 
ments disappear  under  the  use  of  the  rays.  He  has  not  seen  any  patient 
in  whom  a  large  primary  carcinoma  of  the  breast  disappeared  under  the 
use  of  the  X-rays. 

Dr.  G.  G.  Burdick6  reports  a  cure  of  18  cases  of  carcinoma.  In  14 
cases  the  tumor  and  enlarged  glands  disappeared. 

Dr.  W.  B.  Coley7  treated  36  cases  of  carcinoma  of  the  breast.  In 
only  one  instance  did  the  tumor  disappear,  while  in  every  other  case 
there  was  a  recurrence. 

Dr.  A.  D.  Rockwell8  reports  that  in  a  case  of  scirrhus  of  the  breast, 
after  24  post-operative  exposures  there  was  no  evidence  of  return  three 
years  later. 

1  Archives  of  the  Rontgen  Ray,  October,  1906. 

1  Proceedings  of  the  Philadelphia  County  Medical  Society,  October  31,  1904. 

8  Transactions  of  the  American  Rontgen  Ray  Society,  1906,  p.  150. 

4  Ibid. 

&  Ibid. 

•Ibid. 

T  Annals  of  Surgery,  August,  1905. 

•  New  York  Med.  Journal,  April  7,  1906. 


THERAPEUTIC  VALUE  IN  DISEASE.  469 

Dr.  Lassar1  stated  that  he  had  had  only  three  failures  out  of 
hundreds  of  cases  of  cancers  that  he  submitted  to  the  rays. 

He  recognizes2  the  limitations  of  treatment,  stating  that  one-fifth  of 
an  inch  is  the  extent  of  its  effective  therapeutic  penetrating  power. 

Comas  of  Listen  has  had  similar  favorable  results. 

\Vohlgemuth 3  witnessed  the  disappearance  of  a  cancer  of  the  breast 
in  a  woman  of  75  after  72  exposures  thrice  weekly. 

Unger,  of  Berlin,  and  Sjogren,  of  Stockholm,4  know  of  no  case  of 
cure  of  mammary  cancer. 

Djemil  Pasha 5  treated  six  cases  of  cancer ;  three  cases  were  cured 
and  three  improved. 

W.  Johnson  and  "VV.  Merrill 6  treated  seven  cases  of  carcinoma,  all 
of  which  were  inoperable  ;  none  showed  any  improvement  beyond  relief 
from  pain.  They  all  ended  fatally. 

Cancer  of  the  Sternum. — Ferguson7  reported  a  case  of  scirrhus  of  the 
sternum,  which  had  been  declared  inoperable.  The  Rontgen  rays  were 
applied  nineteen  times,  each  exposure  lasting  twenty  minutes.  Three 
weeks  after  the  last  treatment  the  growth  had  almost  entirely  dis- 
appeared. After  the  sixth  treatment  the  excruciating  pain  wholly 
ceased.  Following  the  healing  of  the  ulcerated  field,  there  was  noticed 
a  slight  involvement  of  the  axillary  glands. 

Cancer  of  the  (Esophagus.  —  Pusey 8  records  the  following  case  of 
carcinoma  of  the  oesophagus,  treated  by  the  X-rays:  "Man,  age  56, 
referred  to  me  by  Professor  "VV.  S.  Halsted,  of  Johns  Hopkins  University, 
May  7,  1902.  An  obstruction  in  the  oasophagus  had  been  located  nine 
inches  from  the  teeth.  At  first  a  clinical  diagnosis  of  carcinoma 
was  made.  Subsequently,  Dr.  Halsted  informs  me,  a  piece  of  tissue 
was  removed  through  the  ossophagoscope  and  the  diagnosis  of  adeno- 
carcinoma  was  made  microscopically.  Vigorous  X-ray  exposures  were 
begun  over  the  upper  part  of  the  chest  May  7,  1902,  and  from  that 
time  to  the  present  he  has  had  exposures  daily  except  Sundays,  either 
over  the  chest  or  back,  the  exposures  being  changed  as  erythema  devel- 
oped. There  was  prompt  disappearance  of  the  discomfort  and  pain 
in  the  chest,  and  there  was  a  gradual  improvement  in  his  swallowing. 
Six  weeks  after  beginning  the  exposures,  he  had  gained  nine  pounds 
in  weight,  his  pain  had  disappeared,  and  he  was  having  no  difficulty  in 
swallowing." 

1  Rontgen  Congress,  Berlin,  1905. 
'Journal  of  American  Medical  Asso.,  p.  79. 
'Rontgen  Congress,  Berlin,  1905. 

4  Ibid. 

5  Revue  de  Chirurgie,  Paris,  xxv.,  No.  1. 

6  American  Medicine,  August  9,  1902. 

7  British  Medical  Journal,  1902,  i.  p.  265. 

8  The  Rontgen  Rays  in  Therapeutics  and  Diagnosis. 


470  ELECTRO-THERAPEUTICS. 

Cancer  of  the  Larynx.  — "W.  Scheppegrell l  reports  a  case  of  carcinoma 
of  the  larynx  in  which  a  complete  cure  was  obtained  by  the  rays  alone. 
The  growth  involved  the  left  wall  and  left  vocal  cord.  A  high-tension 
coil  was  employed,  and  a  tube  of  medium  vacuum  was  selected  in  order 
to  gain  some  penetration.  The  face  and  chest  were  protected,  but  the 
neck  was  freely  exposed  in  the  hope  that  any  involvement  of  surround- 
ing glands  might  be  influenced  by  the  treatment.  At  first  the  exposures 
lasted  ten  minutes  and  were  repeated  daily  for  twenty  days.  The  anode 
was  brought  to  a  dull-red  heat,  and  the  vacuum  was  maintained  about 
the  same,  from  the  beginning  to  the  end  of  the  treatment.  At  the  end  of 
three  weeks,  congestion  seemed  more  marked  and  the  tumor  unchanged  ; 
pain,  however,  had  disappeared  after  the  second  exposure.  Ten  days 
later  it  was  found  that  the  tumor  and  most  of  the  symptoms  had  dis- 
appeared. Treatment  was  carried  on  for  ten  days,  by  which  time  the 
ulcers  were  healed.  The  patient,  when  seen  three  months  later,  seemed 
in  good  condition ;  the  aphonia  had  been  practically  overcome  by 
compensatory  over-action  of  the  other  cord. 

Dr.  D.  Bryson  *  believes  that  not  a  single  case  of  laryngeal  cancer 
has  been  reported  cured,  but  few  cases  have  been  thus  treated.  In  one 
case  treated  by  Dr.  W.  J.  Morton  for  the  author,  apparently  good  results 
were  produced  on  the  growth,  but  the  patient  died  of  Bright' s  disease 
after  twenty  applications  of  the  rays. 

Cancer  of  the  Stomach  and  Bowels. — Dr.  P.  M.  Pilcher*  reports  an 
inoperable  carcinoma  of  the  stomach  in  a  woman  of  56.  Three  treat- 
ments of  fifteen  minutes  each  were  given  weekly  ;  they  began  August  1, 
1903,  and  at  the  time  of  the  report  the  patient  was  able  to  eat  and  was 
free  from  pain. 

Dr.  S.  M.  McCollin 4  reports  a  case  of  carcinoma  of  the  stomach  in 
•which  the  swelling  entirely  disappeared  and  the  patient  was  relieved  of 
all  clinical  evidence  of  the  disease. 

Dr.  Finley  R.  Cook5  reports  that  in  carcinoma  of  the  intestines, 
where  life  had  been  threatened  with  intestinal  obstruction,  all  symptoms 
of  obstruction  have  been  relieved,  the  tumor  reduced  in  size,  and  life 
prolonged  for  variable  periods. 

Pusey  says  that  in  carcinoma  of  the  rectum  the  only  hope  in  the 
application  of  the  rays  lies  in  the  decrease  of  pain,  the  checking  of  the 
discharge,  and  the  shrinkage  of  the  growth. 

Cancer  of  the  Herns. — In  applying  the  rays  for  cancer  of  the  uterus, 
I  introduce  a  speculum  and  protect  the  thighs  and  lower  abdomen  with  a 
sheet  of  lead,  exposing  only  the  vulva.  I  employ  a  medium  tube,  at 

1  New  York  Medical  Journal,  December  6,  1902. 

1  The  Laryngoscope,  December,  1902. 

1  Brooklyn  Medical  Journal,  April,  1904. 

4  Proceedings  of  the  Philadelphia  County  Medical  Society,  October  31, 1904. 

6  International  Journal  of  Surgery,  October,  1903. 


THEKAPEUTIC  VALUE  IN  DISEASE. 


471 


a  distance  of  eight  to  ten  inches  (20  to  25  cm.),  thrice  weekly,  exposure 
ten  minutes'  duration.  The  Crookes  tube  with  the  speculum  attached, 
encased  in  a  shield  (Fig.  229),  is  far  superior  to  cavity  tubes  (Figs.  230, 
231),  as  the  latter  lack  the  effective  quality  of  the  Crookes  tube.  X-ray 
workers,  however,  employ  these  tubes.  If  vaginal  dermatitis  is  threat- 
ened, the  rays  may  be  passed  on  alternate  days  through  the  lower  abdomen. 
Dr.  James  P.  Marsh,1  of  Troy,  X.  Y.,  cited  a  case  of  a  woman,  aged 
55,  referred  to  him  for  hysterectomy  because  of  an  extensive  carcinoma 


FIG.  229.— TUBES  AND  RUBBER  TUBE  SHIELDS  *OK  THERAPY  OF  THE  BODY  CAVITIES.— A,  the 
rubber  tube  shield,  encasing  the  tube  and  tied  to  it ;  B,  showing  the  size  of  the  opening  governed  by 
the  diaphragm  ;  C,  showing  speculum  attached.  (R.  V.  Wagner  Co.) 


of  the  cervix.  He  applied  the  rays  alternately  over  the  suprapubic 
region  and  the  vagina,  using  a  very  soft  tube.  The  treatment  was  given 
for  ten  minutes.  After  twenty  or  thirty  treatments  there  was  a  marked 
improvement  in  her  condition.  All  of  the  symptoms  had  disappeared  ; 
she  was  feeling  well  and  gaining  in  weight. 

Therapeutic  Action  of  the  X-rays  in  Cancer. — Dr.  John  G.  Clark,2  at  a 
meeting  of  the  Medical  Society  of  Pennsylvania,  said : 


"During  the 


Journal  American  Med.  Association,  Jan.  17,  1903. 
2  The  Pennsylvania  Medical  Journal,  April,  1904. 


472 


ELECTKO-THEKAPEUTICS. 


last  year  Dr.  Matthew  D.  Mann,  in  a  personal  recital  of  his  own  experi- 
ence,   first  directed  my  attention  to  the  possibilities  of  Eontgen-ray 


OUTER  TUBE 
AIR  SPACE 
INNER  TUBE. 


OUTEf?   TUBE 
A  IP  S PACE 
/NNER    TU&E 

CR05S  SECTION 

FIG.  230.— Pennington's  treatment  (cavity)  tube.    (R.  V.  Wagner  Co.) 


FIG.  231.— Cavity  tube  applied.    (R.  V.  Wagner  Co. ) 

treatment  in  inoperable  cases  and  in  those  in  which  there  is  a  recurrence 
after  operation.  In  the  literature,  which  as  yet  is  not  at  all  well  defined 
concerning  the  active  effects  of  this  agent,  there  appears  a  diversity 
of  opinions;  some  claiming  that  the  curative  action  arises  from  a 


THEKAPEUTIC  VALUE  IX  DISEASE.  473 

stimulation  of  the  nutrition  of  the  part  rather  than  from  an  actual  attack 
upon  the  cancer-cells,  whereas,  others  believe  that  the  rays  act  destruc- 
tively upon  the  cells  by  diminishing  their  growth,  thus  permitting 
the  underlying  connective  tissue  to  reassert  its  functional  activity 
and  reconstruct  the  deficiencies  produced  by  the  invasion  of  the  new 
growth.'' 

Codman,  in  commenting  upon  an  extensive  number  of  cases  treated 
in  the  Massachusetts  General  Hospital,  claims  that  the  beneficial  effects 
of  this  form  of  treatment  arise  from  the  stimulation  of  the  nutrition  of 
the  surrounding  parts,  rather  than  from  a  direct  specific  effect  upon  the 
growth. 

In  the  microscopic  study  of  the  tissues  after  the  Rontgen-ray  treat- 
ment, a  number  of  observers  agree  in  general  as  to  the  structural  changes. 
They  have  found  a  necrosis  of  the  cancer-cells  and  trabeculae,  at  times 
fatty  degeneration,  an  increase  of  elastic  tissue,  and  a  tendency  to  the 
occlusion  of  vessels  by  a  thickening  of  their  inner  walls.  To  the  latter 
effect  is  probably  attributable  the  diminution  of  hemorrhage  frequently 
noted  in  these  cases  after  the  treatment  is  well  under  way. 

C.  SARCOMA. 

What  has  been  said  relative  to  the  results  obtained  in  epithelioma 
and  carcinoma  applies  with  equal  force  to  sarcoma.  I  cannot  believe  that 
many  X-ray  operators  have  achieved  brilliant  results  with  the  rays  in 
this  disease.  I  have  found  that  irradiations  in  sarcomatous  affections  are 
too  often  futile.  Below  are  given  some  of  the  more  interesting  reports 
upon  the  subject. 

Ricketts l  reports  a  case  of  melanotic  sarcoma  of  the  chest  wall.  The 
tumor  had  much  decreased  in  size  and  the  pain  had  almost  totally  disap- 
peared. The  patient  died  in  the  mean  time. 

Carl  Beck2  reports  a  case  of  melanotic  sarcoma  of  the  groin  and 
the  thigh,  recurring  after  operation.  Vigorous  X-ray  treatments  checked 
the  course  of  the  disease. 

S.  \VT.  Allen 3  reports  a  case  of  sarcomatous  growth  of  the  tonsil.  The 
operator  exposed  the  swelling  to  the  influence  of  the  rays,  with  a  result- 
ing decrease  in  the  size  of  the  tumor,  and  at  the  same  time  the  patient 
could  articulate  words  with  much  greater  ease.  Entire  cure  had  not 
been  attained  when  this  report  was  made. 

F.  "Williams4  speaks  of  a  patient  who  had  received  fourteen  treat- 
ments for  sarcoma  of  the  arm,  each  exposure  lasting  from  twelve  to 
twenty  minutes,  the  tumor  being  exposed  twice  in  one  week.  The 

1  Journal  of  the  American  Medical  Association,  1900,  vol.  xxxiv.  p.  76. 

2  New  York  Medical  Journal,  1901. 

3  Boston  Medical  and  Surgical  Journal,  1902,  p.  431. 

4  The  Rontgen  Rays  in  Medicine  and  Surgery. 


474  ELECTRO-THERAPEUTICS. 

induration  had  disappeared  almost  entirely,  the  swelling  had  dimin- 
ished considerably,  and  the  venous  discoloration  over  the  tumor  had 
given  way  to  the  normal  hue  of  the  skin. 

Scholtz1  reports  the  results  obtained  in  the  treatment  of  two  cases 
of  multiple  sarcomata  of  the  skin.  He  states  that  under  active  applica- 
tions small  nodules  of  the  integument  disappeared  entirely.  Jamieson's 
case  of  mycosis  fungoides  which  was  treated  with  the  X-rays  showed 
very  marked  improvement  in  every  respect. 

Dr.  George  Erety  Shoemaker  *  reports  the  case  of  a  woman  who  had 
sarcoma  of  the  abdominal  wall,  and  probably  also  of  the  pelvic  viscera, 
which  disappeared  under  treatment.  On  operation  it  was  found  that  the 
rectum,  the  uterus,  and  the  left  tube  and  ovary  were  massed  together  by 
an  apparent  infiltration,  but  had  a  certain  range  of  motion.  The  tumor 
in  the  lower  abdominal  wall  was  united  to  this  mass  by  a  process  of 
thickened  tissue  a  little  to  the  left  of  the  median  line.  ,The  whole 
appearance  suggested  a  new  growth,  which  it  was  thought  unwise  to 
remove.  The  incision  was  closed,  and  a  cut  made  directly  into  the 
suprapubic  growth.  Examination  of  the  piece  removed  for  that  purpose 
showed  that  the  mass  was  sarcomatous.  Treatment  by  the  Rontgen  rays 
was  begun  after  the  healing  of  the  upper  wound.  This  treatment  con- 
tinued for  about  nine  months  in  all.  The  total  number  of  exposures  was 
forty-nine.  The  improvement  was  remarkable.  A  year  after  coming 
under  observation  the  infiltration  of  the  abdominal  wall,  the  pain,  and 
the  soreness  were  entirely  gone. 

In  a  case  reported  by  Richmond,3  the  patient  had  a  swelling  which 
crowded  the  liver  and  other  organs  forward  and  inward.  A  diagnosis  of 
sarcoma  was  made.  After  treatment  with  the  X-rays  for  nineteen 
consecutive  days  the  temperature  had  decreased  to  normal,  night-sweats 
were  lessened,  the  tumor  had  apparently  ceased  to  grow  and  seemed 
softer,  and  the  patient  was  generally  improved.  She  was  then  sent  to  the 
hospital,  where  the  treatment  was  continued,  and  at  the  end  of  nine 
weeks  the  growth  had  entirely  disappeared,  as  far  as  could  be  determined 
by  bimanual  examination. 

McMaster*  reports  five  cases  of  sarcoma  in  which  treatment  with 
the  X-rays  proved  entirely  successful. 

Dr.  L.  Webster  Fox,5  of  Philadelphia,  had  his  attention  called  to 
X-ray  treatment  in  epithelioma  of  the  lids.  A  year  and  a  half  ago  he 
had  a  case  of  sarcoma  of  the  orbit ;  the  diagnosis  was  confirmed  by 
several  colleagues  and  by  the  microscope.  The  case  received  forty-eight 

1  Archiv  f.  Derm.  u.  Syph.,  1902,  lix.  p.  42. 

*  American  Medicine,  December  26,  1903. 

"Journal  of  the  American  Medical  Association,  June  10,  1903. 

4  Canada  Lancet,  February,  1903. 

6  Journal  of  the  American  Medical  Association,  December  17,  1904. 


THERAPEUTIC  VALUE  IX  DISEASE.  475 

applications  of  the  X-rays  before  the  disappearance  of  the  growth.  There 
was  no  recurrence. 

J.  G.  Chrysopathos '  operated  on  a  woman  who  had  a  large,  rapidly 
growing  tumor  of  the  right  ovarian  region  ;  finding  it  to  be  a  sarcoma  (a 
diagnosis  which  was  confirmed  by  microscopic  examination),  he  began  to 
treat  it  with  Eontgen  rays.  She  was  treated  two  or  three  times  weekly, 
and  after  about  eight  months  was  discharged  as  cured.  Xeither  abdom- 
inal nor  vaginal  examinations  offered  the  slightest  abnormality.  She  is 
now  treated  about  once  every  two  or  three  weeks,  and  has  been  well  for 
some  months. 

The  tumor  in  the  case  cited  by  Skinner2  was  situated  in  the  lower 
part  of  the  abdominal  wall,  in  the  region  of  the  cicatrix  resulting  from  a 
laparotomy,  performed  three  years  before,  for  what  was  regarded  as  a 
fibroid  uterine  tumor.  The  fibro-sarcoma  was  of  the  size  of  a  cocoanut, 
filling  up  the  entire  iliac  fossa,  extending  nearly  to  the  umbilicus  and 
two  inches  beyond  the  median  line  to  the  left.  The  tumor  was  very 
firmly  fixed  and  seemed  to  involve  the  abdominal  wall.  Erysipelas  toxins 
were  used  for  ten  months.  During  the  first  two  months  the  growth 
decreased  more  than  half  in  size,  and  for  a  long  time  thereafter,  while 
there  was  no  decrease,  there  was  no  distinct  growth.  Later  on  the 
influence  of  the  toxins  seemed  to  have  become  lost,  and  there  was  a  slow 
but  gradual  increase  in  size.  X-ray  treatment  was  then  begun.  The 
patient  received  one  hundred  and  thirty-six  exposures  within  seven 
hundred  and  thirty-nine  days  ;  two  applications  were  given  in  the  course 
of  every  five  days  at  the  beginning  of  the  treatment,  and  later  on,  one  in 
five  days,  fifteen  days,  and  thirty-seven  days.  Twenty-eight  months 
after  beginning  the  treatment,  the  patient  had  increased  considerably 
in  weight  and  the  tumor  had  entirely  disappeared. 

Beclere 3  reports  the  case  of  a  patient  affected  with  sarcoma  of  the 
floor  of  the  orbit  who  was  cured  by  X-rays.  The  disease  had  lasted  four 
years.  Two  operations  had  been  performed,  the  last  one  including 
removal  of  the  eye.  All  other  methods  of  treatment  had  failed,  but 
improvement  set  in  as  soon  as  radiotherapy  was  employed.  Histologi- 
cally,  the  tumor  was  found  to  be  a  malignant  sarcoma.  Beclere  reports 
an  additional  case  of  orbital  sarcoma  cured  by  X-rays. 

Kienbock  *  reports  a  sarcoma  cured  by  X-rays.  This  case  is  of  very 
unusual  interest.  A  growth,  having  appeared  in  the  nose  seven  years 
before,  in  spite  of  operations  oft  repeated,  had  invaded  the  adjoining 
structures  and  produced  exophthalmos  on  both  sides,  with  subsequent 
optic  atrophy.  Pain  ceased  after  the  first  treatment,  and  after  thirteen 

1  Munch,  med.  "Wochens.,  1,  50. 

'Archives of  Electrology  and  Radiology,  October,  1904. 
s  Gaz.  dea  Hop.,  June  14,  1904. 

4  Quoted  by  Dr.  G.  Oram  Ring,  "  The  Value  of  X-Rays  in  Ocular  Therapeutics," 
Journal  American  Medical  Association,  September  29,  1906. 


476  ELECTRO-THERAPEUTICS. 

applications  the  growth  (an  endothelial  sarcoma)  entirely  disappeared. 
The  eyes  resumed  their  normal  appearance  and  vision  partly  returned. 
Grossman '  reports  a  similar  case  which  had  almost  entirely  disappeared 
under  the  X-rays.  Theobald 2  has  had  one  case  of  marked  exophthalmos 
(unpublished)  with  the  diagnosis  of  inoperable  sarcoma  of  the  orbit — a 
diagnosis  in  which  two  other  surgeons  concurred.  Under  the  X-ray 
treatment  the  case  rapidly  improved  and  after  a  lapse  of  seven  months 
seemed  to  be  cured. 

\V.  B.  Coley 8  treated  167  malignant  growths,  scattered  over  many 
parts  of  the  human  body,  and  arrives  at  the  conclusion  that,  while  the 
X-rays  are  of  inestimable  value  in  skin  cancers,  nevertheless  the  latter 
often  recur,  and  that  undoubtedly  surgery  is  in  these  cases  far  preferable. 
He  is  opposed  to  the  use  of  the  rays  in  deep-seated  carcinomas  and 
sarcomas,  believing  their  value  very  slight  and  temporary.  Where  the 
neoplasm  had  apparently  disappeared,  metastases  quickly  occurred.  He 
believes  that  irradiation  is  palliative  in  those  cancers  that  are  for  any 
reason  inoperable.  He  asserts  that  post-operative  irradiation  rests 
purely  on  theoretical  grounds  and  needs  further  study  as  to  its  value  or 
usefulness  in  these  cases. 

1  believe  that  in  many  instances,    where    brilliant    results    were 
achieved    in    irradiation    of   sarcomas,    in    all    probability   there   was 
a  mistake  in  the  diagnosis  and  a  less  malignant  affection  was  present, 
or  else  the  operators  were  a  little  too  enthusiastic  when  making  their 
reports. 

George  C.  Johnston  *  reports  three  cases  of  inoperable  and  recurrent 
sarcoma  successfully  treated  by  the  X-rays.  The  diagnoses  were  made 
clinically  and  pathologically.  Xo  auto-intoxication  occurred. 

Djemil  Pasha,  of  Constantinople,5  reports  that  a  case  of  sarcoma  of 
the  breast  seemed  rather  aggravated  by  treatment. 

Dr.  W.  B.  Coley 6  treated  68  cases  of  sarcoma.  He  obtained  complete 
disappearance  of  the  tumor  in  five  of  them. 

Dr.  Russell  H.  Boggs T  treated  five  cases  of  sarcoma.  In  two  of  them 
the  growth  was  reduced  in  size,  but  improvement  was  temporary.  Later, 
both  patients  died. 

G.  G.  Burdick8  treated  34  patients;  18  are  considered  cured.  The 
tumors  disappeared  completely  and  are  giving  no  trouble  whatsoever. 

'Quoted  by  Dr.  G.  Gram  Ring,  "The  Value  of  X-Rays  in  Ocular  Therapeutics," 
Journal  American  Medical  Association,  September  29, 1906. 

2  Ibid. 

*New  York  Medical  Journal,  April  7,  1906. 

4  Journal  of  Advanced  Therapeutics,  1904,  p.  648. 

*  Revue  de  Chirurgie,  Paris,  xxv.,  No.  1. 

•Annals  of  Surgery,  August,  1905. 

T  Transactions  of  the  American  Rontgen  Ray  Society,  1905,  p.  115. 

•Ibid.,  p.  112. 


FIG.  232.— SARCOMA  OF  THE  LEO.— 1  and  2  show  areas  of  recurrence  ;  3  indicates  the  part  that  I  irradiated. 


FIG.  233.— Skiagraph  of  the  same. 


THERAPEUTIC  VALUE  IX  DISEASE.  477 

The  patients  are  following  their  usual  vocations.  I  think  Dr.  Burdick 
has  overstated  these  facts. 

Dr.  Charles  E.  Dickson,1  of  Toronto,  exposed  within  one  year  a  case 
of  recurrent  sarcoma  48  times  to  the  rays.  The  symptoms  disappeared 
completely  and,  though  the  case  was  discharged  about  one  year  ago,  the 
sarcoma  has  not  shown  any  signs  of  returning. 

All  of  my  cases  ended  fatally,  although  I  have  seen  the  same  tem- 
porary improvements.  In  one  of  my  cases  a  sarcoma  of  the  leg  showed 
the  slow  progress  of  the  disease,  and  repeated  recurrences  even  under 
vigorous  X-ray  treatment  were  noted. 

I  treated  a  patient,  aged  30,  who  in  the  spring  of  1900  noticed  a 
small  tumor  of  the  right  leg  about  two  inches  above  the  ankle.  The 
neoplasm  was  removed  one  month  later  and  diagnosed  microscopically  as 
a  sarcoma.  Three  years  later  there  was  a  recurrence.  I  then  proceeded 
to  irradiate  the  part.  I  treated  him  for  six  weeks,  thrice  weekly,  each 
treatment  of  ten  minutes'  duration.  The  patient  completely  recovered. 
In  June,  1905,  the  vicinity  of  the  scar  became  sarcomatous  and  was 
operated  upon  by  Dr.  Babcock.  In  September,  1905,  he  returned  to  me, 
as  the  sarcoma  was  again  recurring  around  the  former  seat,  and,  because 
he  complained  of  pains  in  the  chest,  I  skiagraphed  the  latter  and  found 
in  the  lung  sarconiatous  rnetastases.  The  patient  became  very  despondent 
and  ended  his  life.  (Figs.  232  and  233.) 

III.   Constitutional  Diseases. 
A.  TUBERCULOSIS. 

The  value  of  the  X-rays  in  tuberculous  affections  is  at  present  unde- 
termined. The  varying  stages  of  the  disease,  the  inexactness  of  the 
reports  recorded,  and  the  particular  behavior  of  the  malady  in  the  differ- 
ent structures  invaded,  make  it  advisable  to  append  the  following  reports 
from  experienced  investigators. 

Bergoni6  and  Teissier2  give  some  of  the  results  obtained  in  experi- 
menting with  the  X-rays  upon  tubercle  bacilli.  They  conclude  that 
animals  infected  with  tuberculosis  and  subjected  for  varying  periods  of 
time  to  the  action  of  the  rays  die,  for  the  most  part,  without  any  appre- 
ciable change  in  the  lesions  and  without  any  retardation  in  the  course  of 
the  disease. 

Dr.  Kennon  Dunham3  said  that  he  had  found  that  the  X-rays  do 
not  affect  the  tubercle  bacillus  to  any  appreciable  extent.  He  believes 
that  the  favorable  results  obtained  by  treating  tuberculous  patients  are 
not  due  to  a  destruction  of  the  bacillus,  but  to  the  stimulation  of 

1  Journal  of  Advanced  Therapeutics,  1904,  p.  654. 

1  Arch,  d'  Electric! te  Medicale,  15,  xi.,  and  15,  xii.,  1898. 

s  Proceedings  of  the  American  Runtgen  Ray  Society,  1903. 


4  7  s  ELECTRO-TH  ER  APEUTICS. 

the  tissues.  He  had  obtained  good  results  by  simply  wrapping  the 
patient  in  a  coil  of  copper  wire  connected  with  one  pole  of  a  high- 
frequency  current. 

Chisholm  Williams,1  in  an  article  read  before  the  members  of  the 
Electro-Therapeutic  Sub-section  of  the  British  Medical  Association  in 
1901,  stated  that,  of  the  forty-three  cases  of  pulmonary  tuberculosis 
treated  by  the  X-rays,  only  three  had  died,  the  immediate  cause  of  death 
being  pneumonia,  tuberculosis  of  kidney,  and  lardaceous  disease.  During 
the  treatment  the  temperature  of  the  patient  uniformly  rose,  the  rise 
depending  upon  the  duration  and  strength  of  the  treatment.  Xight- 
sweats  increased  at  first,  but  gradually  disappeared.  The  number  of 
bacilli  in  the  sputum  increased  early  in  the  treatment,  but  later  on 
formed  clumps,  became  short  and  stumpy,  took  a  stain  more  read- 
ily, and  later  in  the  treatment  began  to  decrease.  The  disease  has 
been  arrested  when  the  patient  can  take  daily  treatments  of  half 
an  hour  or  more  without  showing  a  rise  of  temperature  during  the 
treatments. 

Dr.  Russell  H.  Boggs2  cited  six  cases  of  tuberculosis  treated  by  him 
with  the  X-rays.  One  of  the  cases  has  remained  cured  for  over  a  year. 
One  case  died  from  an  intercurrent  affection,  and  the  other  four  are 
decidedly  improved  in  every  way. 

Dr.  J.  D.  Gibson 3  cited  a  case  of  tuberculosis  complicated  by  a  very 
large  cirrhotic  liver.  After  a  treatment  of  six  weeks  the  symptoms  were 
markedly  improved.  The  treatment  was  discontinued  ;  the  patient  went 
home  and  died.  While  the  rays  do  not  cure,  yet  they  improve  every 
case,  even  the  most  desperate  and  hopeless. 

Rudis-Jicinsky 4  states  that  he  has  employed  the  X-rays  together 
with  other  forms  of  treatment  in  19  selected  cases  of  pulmonary  tubercu- 
losis. Of  these  he  states,  in  one  year,  one  died. 

Drs.  Boido  and  Boido 5  report  fourteen  cases  of  tuberculosis  treated 
by  means  of  the  X-rays.  The  treatment  had  been  conducted  in  Tucson, 
Arizona,  which  has  an  altitude  of  2300  feet,  and  a  climate  that  is  warm 
and  dry.  The  fourteen  cases  reported  were  all  Mexicans,  afflicted  with 
pulmonary  tuberculosis  in  varying  stages  of  disease.  It  is  their  opinion 
that  in  treating  such  cases  it  is  beneficial  to  the  patient  to  employ  a  tube 
which  produces  rays  that  induce  a  dermatitis,  claiming  that  such  rays  are 
of  real  therapeutic  value.  In  making  the  exposures  the  vacuum  tube  was 
placed  3  to  4  inches  (8  to  10  cm.)  distant  from  the  skin.  Exposures  were 
made  both  anteriorly  and  posteriorly,  allowing  five  minutes  for  each  side 
of  the  chest.  After  these  exposures  ten  of  the  fourteen  cases  had  been 

1  Archives  of  the  Rontgen  Ray,  August,  1903,  p.  48. 
*  Ibid.  » Ibid. 

4  The  New  York  Medical  Journal,  March  2, 1901,  pp.  364,  365. 

5  American  Electro-Therapeutics  and  X-Ray  Era,  February,  1903. 


THERAPEUTIC  VALUE  IN  DISEASE.  479 

relieved  of  the  pulmonary  pain.  The  number  of  exposures  varied  in 
each  case.  Their  reports  show  that  three  deaths  occurred  in  three  years, 
and  the  remaining  eleven  are  still  living. 

J.  B.  Ransom1  reports  treatment  of  forty  cases  of  tuberculosis  in 
the  lungs  and  other  parts  of  the  body.  He  specifies  that  the  Rontgen 
rays,  and  also  the  ultra-violet  rays,  are  especially  indicated  for  treating 
tuberculous  lesions  located  more  or  less  superficially.  As  regards  deep- 
seated  pulmonary  lesions  the  number  of  such  cases  treated  is  entirely  too 
small  and  the  time  that  has  elapsed  is  too  brief  to  arrive  at  any  definite 
conclusions.  He  believes  that  the  Rontgen  rays  may  soon  prove  to 
be  a  valuable  therapeutic  agent  in  this  class  of  diseases.  He  also  asserts 
that  pain  is  relieved  and  sleep  is  permitted ;  the  local  circulation  is 
stimulated  and  expectoration  is  considerably  lessened. 

Hahn 2  states  that  Rieder  had  applied  the  X-rays  to  the  thorax  of  a 
patient  suffering  with  a  chronic  form  of  pulmonary  tuberculosis,  and  the 
results  obtained  were  not  encouraging  in  any  way  as  was  primarily 
expected. 

G.  E.  Pfahler  *  says  that  early  in  the  history  of  the  X-rays  physi- 
cians noted  relief  from  pain,  and  to  a  degree  from  other  symptoms,  in 
cases  of  tuberculosis  of  the  joints  which  had  been  examined  repeatedly 
by  means  of  the  rays.  He  says  that  J.  B.  Murphy  treated  two  cases 
of  tuberculosis  of  the  knee-joint  in  which  the  synovial  membrane  was 
involved.  Both  of  the  joints  had  been  treated  by  injections  without 
improvement.  One  patient  in  whom  the  effusion  had  persisted  nine 
months  was  discharged  as  recovered  after  21  days  in  the  hospital,  the 
effusion  having  disappeared.  Murphy  also  reports  three  cases  of  spinal 
tuberculosis  treated  with  the  X-rays.  The  first  case  was  one  in  which 
the  patient  developed  paraplegia.  Pus  and  tuberculous  debris,  which 
established  the  diagnosis,  were  removed  with  a  hypodermic  needle. 
After  the  third  application  of  the  rays  the  pain  disappeared,  and  after 
twenty-five  applications  the  paraplegia  was  cured.  A  second  case  was 
one  in  which  laminectomy  had  been  performed  a  year  before.  The 
patient  was  worse  after  the  operation,  and  a  sinus  was  left,  but  this  healed 
completely  after  twenty  applications  of  the  rays.  The  paraplegia  in  this 
case  was  not  improved.  The  third  case  was  that  of  a  paraplegic,  whose 
pain  was  controlled  by  large  doses  of  morphia.  Two  exposures  relieved 
pain,  and  after  the  twenty-third  irradiation  he  got  about  on  crutches. 

Henry  K.  Pancoast  *  mentions  the  results  obtained  in  the  treatment 
of  deep-seated  lesions  of  the  larynx,  lungs,  peritoneum,  joints,  and  spine 
with  the  X-rays.  He  found  that  tuberculous  laryngitis  maybe  aided  and 
even  cured  by  X-ray  treatment,  provided  there  can  be  brought  about  an 

1  Medical  Record,  February,  27, 1904. 

2  Fortschritte  a.  d.  Geb.  d.  Rontgenstr.,  B.  iii.,  H.  3,  p.  119. 

3  Philadelphia  Medical  Journal,  February  14,  1903. 

4  Therapeutic  Gazette,  August,  1905. 


480  ELECTRO-THERAPEUTICS. 

improvement  iu  the  primary  pulmonary  condition.  Too  vigorous  treat- 
ments will  cause  a  reaction  which  may  be  carried  to  an  unfavorable 
degree ;  therefore,  great  care  is  necessary  in  determining  the  proper 
dosage  in  each  case.  Pulmonary  lesions  in  selected  cases  may  be  bene- 
fited probably,  but  even  greater  precautions  should  be  observed.  He 
does  not  consider  Finsen-light  applications  of  any  value  in  treating 
laryngeal  lesions.  Only  the  most  powerful  lamps  need  be  tried,  and  such 
exposures  are  of  value  only  in  lessening  or  retarding  a  skin  reaction  from 
the  X-rays. 

Ausset  and  Bedart l  treated  a  case  of  tuberculous  peritonitis  in  a  girl, 
nine  years  of  age,  by  tapping  and  abdominal  section,  but  with  negative 
results.  During  this  treatment  her  condition  grew  steadily  worse,  and 
the  tuberculous  masses  in  the  abdomen  steadily  enlarged.  On  March  7, 
she  was  first  subjected  to  the  X-rays,  the  Crookes  tube  being  placed  20 
cm.  from  the  surface  of  the  abdomen  for  ten  minutes,  two  days  later  at  13 
cm.  Throughout  the  month  the  treatment  was  continued  every  two  or 
three  days.  During  most  of  the  following  month  the  treatment  was 
unavoidably  discontinued.  During  the  latter  part  of  May  there  was 
absolutely  no  abdominal  effusion.  From  this  time  on,  she  steadilj-  im- 
proved, gaining  in  weight  and  strength,  until  she  became  apparently  well. 

Southgate  Leigh  *  cites  a  case  of  tuberculosis  of  the  elbow-joint.  The 
joint  had  been  exposed  to  the  rays  for  a  period  of  two  hours,  and  as  often 
as  two  or  three  times  in  a  week.  After  twelve  hours'  exposure  the 
inflammatory  process  entirely  disappeared ;  no  recurrence  appeared  in 
the  eighteen  months  that  had  since  elapsed. 

Dollinger3  reports  for  Kirmisson  a  case  of  tuberculosis  of  the  wrist- 
joint.  The  part  had  been  exposed  for  ten  minutes  daily  for  a  period  of 
two  and  a  half  months.  The  result  was  an  improvement,  and  by  the 
subsequent  application  of  electricity  the  part  was  absolutely  cured. 

Tousey 4  is  of  the  opinion  that  judicious  application  of  the  X-rays,  or 
of  the  ultra-violet  rays  and  high-frequency  currents,  is  indicated  in  every 
case  of  tuberculosis,  especially  tuberculosis  of  the  larynx.  One  case,  in 
point,  is  reported  in  which  the  treatment  was  remarkably  successful.  The 
expectoration  ceased  in  three  weeks ;  there  was  great  improvement  in 
the  voice,  marked  gain  in  strength,  normal  temperature,  and  a  gain  in 
body  weight  of  about  three  pounds.  The  local  condition  also  has  im- 
proved, an  area  of  infiltration  has  diminished,  and  the  abrasions  have 
healed  with  a  whitish  appearance,  which  may  be  due  to  cicatricial  tissue. 
The  treatment  consisted  first  in  exposure  to  the  X-rays  once  every 

1  L'Echo  MeU  du  Nord,  No.  46, 1898. 

1  Reported  by  Werner  in  the  Fortsch.  a.  d.  Geb.  d.  Rontgenstrahlen,  B.  Hi.,  H.  3, 
pp.  122,  123. 

'Fortech.  a.  d.  Geb.  d.  Rontgenstr.,  B.  ii.,  p.  72. 
*  Medical  Record,  September  3,  1904. 


THERAPEUTIC  VALUE  IX  DISEASE.  481 

four  or  five  days  ;  exposure  to  the  Cooper- Hewitt  light  and  application 
of  high-frequency  currents  once  in  each  interval  between  the  X-ray 
applications. 

Dr.  M.  C.  Rice 1  reported  the  case  of  a  woman,  whose  mother  and 
sister  had  both  had  enlarged  glands,  suppuration  having  occurred  in  the 
case  of  the  mother.  The  patient  had  a  chain  of  enlarged  glands  extend- 
ing from  the  ear  to  the  clavicle  ;  the  largest  one,  situated  below  the  ear, 
was  the  size  of  a  hen's  egg.  These  glands  had  been  somewhat  enlarged 
for  five  years,  but  had  been  growing  rapidly  for  four  months.  The  patient 
had  been  taking  iodides  for  some  time.  After  three  months  of  treatment 
with  the  high-frequency  current,  by  means  of  the  Tesla  coil  and  static 
machine,  with  only  slight  improvement,  Rontgen  rays  were  substituted, 
after  which  the  patient  improved.  After  five  months'  treatment  the 
glands  could  scarcely  be  felt. 

Dr.  E.  H.  Grubbe2  has  had  under  treatment  more  than  thirty  cases 
of  tuberculosis  of  the  cervical  lymph-glands,  most  of  them  in  children, 
and  superficial.  From  the  results  he  obtained,  he  feels  that  he  can  make 
great  claims  for  the  Rontgen-ray  treatment  of  this  condition.  Of  course, 
he  prefers  to  treat  them  when  they  are  primary  cases,  because  one  cannot 
get  such  good  results  after  the  disease  has  extended  to  the  deep  glands 
nor  after  surgical  interference. 

Dr.  Russell  H.  Boggs 3  asserts  that  the  results  obtained  by  the  Ront- 
gen rays  in  the  treatment  of  tuberculous  adenitis  compare  favorably  with 
those  obtained  by  any  other  method.  A  large  proportion  of  the  cases  can 
be  apparently  if  not  permanently  cured.  Several  cases  have  remained 
cured  for  over  four  years.  Improvement  is  not  attained,  as  a  rule,  until  at 
least  twelve  treatments  have  been  given.  There  are  exceptions,  however, 
one  patient  being  improved  after  four  treatments,  and  others  not  improv- 
ing until  after  twenty-five  or  more  exposures.  A  permanent  cure  should 
not  be  expected  until  after  at  least  three  mouths'  treatment.  He  advised 
that  in  treating  these  cases  the  apices  of  the  lungs  should  also  be  rayed. 
To  be  beneficial,  treatment  must  be  energetic. 

In  tuberculous  adenitis  that  has  advanced  to  suppuration,  my  prefer- 
ence is  to  have  the  patient  submit  to  surgical  interference  and  to  the 
subsequent  employment  of  irradiations.  Early  in  tuberculous  adenitis, 
the  rays  are  useful  in  aborting  the  affection  by  the  formation  of  fibrous 
tissue  within  and  around  the  gland. 

Dr.  James  B.  Bullitt,4  in  a  "comparison  of  Rdntgen-rays  and  sur- 
gical treatment  of  tuberculosis,"  says:  "I  have  collected  518  cases  of 
surgical  forms  of  tuberculosis,  reported  by  forty-eight  observers ;  most 
of  these  have  come  through  personal  communication ;  a  few  have  been 

1  Transactions  of  the  Rontgen  Ray  Society,  1905.  2Ibid. 

8  Journal  of  the  American  Medical  Association,  September  15,  1906. 
*  Transactions  of  the  American  Rontgen  Ray  Society,  September,  1904. 
31 


482 


ELECTRO-THEK  A  PEl'TICS. 


collected  from  the  literature.  The  following  is  the  tabulated  list  showing 
the  number  of  cases  of  each  kind  and  the  number  and  percentage  of  cases 
in  each  of  the  three  divisions  of  the  classification  : 


No.  Patients 
treated. 

Cured. 

Improved. 

Unim- 
proved. 

Tuberculosis  of  long  and  flat  bones  
Tuberculosis  of  joints  

71 
141 

26(36$) 
54(38$) 

25(35$) 
53  (87 

21  (29',i 

34  (25',  ) 

Tuberculosis  of  tendon  sheaths  

27 

19(70$) 

6  (22$  ) 

2(,~ 

Tuberculosis  of  peritoneum  

32 

13  (40$) 

8  (25$  ) 

19  (35$) 

Tuberculosis  of  testicle  

21 

7  (335?  ) 

10  (48$) 

4(19$) 

Tuberculosis  of  lymphatic  glands  

00,5 

79(35$) 

92(40$) 

55(25;,) 

Tuberculosis  of  ekin  (lupus)  

518 
616 

420(68$) 

148  (24'^  ) 

48  (8$)" 

Drs.  P.  Eidard  and  Barret 1  report  successful  results  iu  treating  osteo- 
arthritis  and  tuberculous  osteitis;  also  they  noticed  improvement  iu 
several  cases  of  arthritis  accompanied  by  fibrous  aukylosis.  Irradiations, 
lasting  seven  minutes,  were  given  with  intervals  of  twelve  to  fifteen  da  vs  : 
by  using  a  thin  leaf  of  aluminium  filter  no  dermatitis  was  produced. 

I  treated  a  number  of  cases  of  large  areas  of  tuberculosis  of  the  skin. 
In  Figs.  234  and  235  are  shown  the  ravages  of  cutaneous  tuberculosis  in 
a  youth  of  21.  In  the  left-hand  photograph  is  the  view  of  the  face  and 
neck  when  the  patient  first  presented  himself  at  the  Philadelphia  Hos- 
pital for  treatment.  In  the  right-hand  picture  are  shown  the  results  of 
X-ray  treatment  in  the  disappearance  of  all  the  elevations,  white  areas 
replacing  the  former  sites  of  tuberculous  deposits. 

B.  LEUKJEMIA. 

The  value  of  the  X-ray  treatment  of  leukaemia  is  a  matter  of  dis- 
cussion. Many  authorities  assert  that  cases  of  this  disease  have  been 
permanently  cured  by  the  repeated  application  of  the  rays ;  other  inves- 
tigators, equally  distinguished,  maintain  that  Rontgeu  treatment  is  a 
valuable  adjunct  only  to  the  usual  remedial  agents  employed.  At  the 
conclusion  of  this  article,  some  views  on  the  subject,  which  are  worthy 
of  perusal,  are  appended. 

Fried1  stated,  that  iu  a  case  of  inoperable  carcinoma  of  the  mammary 
gland  and  in  a  second  case  of  iiitra-abdoininal  sarcoma,  treatment  by  the 
X-rays  showed  a  great  decrease  in  the  number  of  white  corpuscles  and 
an  increase  in  the  reds. 

Inseen  s  reports  two  cases  of  pseudo- leukaemia  treated  by  the  X-rays, 

•Arch,  d' Electricity  Medicale,  February,  1906. 

1  American  Medicine,  June,  1902. 

•New  York  Medical  Journal,  April  8, 1903. 


THEKAPErXIC  VALUE  IX  DISEASE.  483 

in  which  marked  improvement  was  noted.  On  account  of  the  toxtemia 
set  up  in  each  case,  the  treatments  had  to  be  suspended  for  a  short  period. 
He  believes  that  the  rays  will  prove  to  be  a  means  of  curing  a  heretofore 
incurable  disease. 

Xicliolas  Seun l  reports  the  treatment  with  X-rays  of  two  patients, 
far  advanced  in  pseudo-leukaemia.  In  the  first  patient,  after  34  applica- 
tions of  the  X-rays,  all  the  enlarged  glands  had  almost  entirely  dis- 
appeared and  the  general  condition  was  much  improved.  When  dis- 
charged, no  glands  were  palpable  ;  the  blood,  however,  did  not  show  any 
characteristic  changes.  The  second  patient  showed  universal  enlargement 
of  the  lymphatic  glands.  The  blood  examination  revealed  a  well  marked 
ameiuia  and  a  leucocytosis  of  208,000,  the  increase  being  most  marked  in 
the  lymphocytes  (78.75  per  cent.).  This  patient  was  also  treated  with 
the  X-rays,  and  after  fifteen  exposures  he  developed  a  slight  toxaemia  ; 
treatment  was  then  discontinued.  However,  the  general  condition  of  the 
patient  was  much  improved  ;  all  palpable  glands  were  diminished  in  size 
and  the  number  of  leucocytes  was  reduced  to  76,000.  The  treatment  was 
again  renewed,  and  progressive  improvement  continued,  the  patient  being 
discharged  practically  cured. 

Meyer  and  Eisenreich2  reported  two  cases  of  myeloid  leukaemia 
treated  with  the  Rontgen  rays.  They  differ  in  several  points  from  others 
that  have  been  published.  The  first  patient,  aged  31,  was  a  machinist 
by  occupation.  Blood  findings  altered  completely  under  the  influence 
of  the  rays,  and  a  marked  leucocytosis  followed,  with  mast-cells  predomi- 
nating. By  the  end  of  four  months  the  leucocytes  had  fallen  from 
10.").  000  to  6100,  but  then  rose  again  to  about  22,000,  and  later  to  35,000. 
The  blood  findings  altered  so  materially  under  the  influence  of  the  rays 
that  no  one  would  have  suspected  leukaemia  from  the  blood  picture.  The 
spleen  returned  to  normal  size  in  the  first  case,  but  remained  enlarged  in 
the  second  case,  in  which  the  leukaemia  was  of  longer  standing  and 
the  symptoms  more  serious.  Since  suspension  of  the  treatment,  the  blood 
findings  have  displayed  a  tendency  to  return  to  the  leukaemic  picture,  so 
that  the  hope  of  actually  curing  leukaemia  by  this  means  is  not  very 
promising. 

Wcndel,  of  Marburg,  has  collected  from  the  literature  38  cases  of 
leukaemia  treated  with  the  X-rays  and  adds  another  to  the  list.  He 
tabulates  the  details  of  the  various  cases  and  states  that  more  than 
90  per  cent,  were  favorably  influenced.  In  two  instances  no  appre- 
ciable benefit  was  observed,  and  in  two,  the  disease  rapidly  progressed 
notwithstanding  the  treatment. 

Dr.  Steinwand,3  of  Selma,  Cal.,  reports  a  case  of  pseudo- leukaemia 

1  New  York  Medical  Journal,  April  18,  1903. 

2  Miinchener  medicinische  Wochenschrift,  January  24, 1904. 

3  Journal  of  the  American  Medical  Association,  March  26,  1904. 


4S4  ELECTRO-THERAPEUTICS. 

successfully  treated  by  the  X-rays:  "The  patient,  a  school-girl,  aged 
15.  Family  history  :  Mother  died  from  heart  disease  two  years  ago ; 
father  well ;  three  brothers,  two  of  them  are  well,  one  has  chronic 
stomach  trouble ;  three  sisters,  all  well.  Xo  tuberculous  or  syphilitic 
history. 

"About  five  or  six  years  ago  the  glands  on  the  left  side  of  her  neck 
became  enlarged,  but  were  not  painful.  During  the  succeeding  years 
they  increased  slowly  but  gradually,  and  there  were  occasional  sharp 
pains  in  the  splenic  region.  Two  years  later  the  glands  along  both 
borders  of  the  sterno-mastoid  muscle  began  to  coalesce  and  rapidly 
increase  in  size.  The  supraclavicular  glands  also  became  prominent,  and 
later  the  axillary  glands  were  involved. 

"The  patient  came  for  treatment  April  1,  1903.  She  presented  all 
the  symptoms  above  enumerated,  with  rapidly  increasing  nervous 
phenomena  and  steady  loss  of  weight.  All  the  treatment  she  had 
received  was  ineffective  in  checking  the  course  of  the  disease.  There 
had  not  been  any  definite  diagnosis. 

"There  were  large  glandular  masses  on  the  left  side  of  the  neck, 
anterior  and  posterior  to  the  sterno-cleido-inastoid  muscles,  the  larger 
ones  about  the  size  of  a  hen's  egg.  They  were  movable  under  the  skin,  but 
bound  down  more  or  less  to  the  deeper  structures.  The  spleen  was  some- 
what enlarged  and  tender  to  pressure.  Temperature  was  100°  to  101°. 
The  haemoglobin  index  was  70  per  cent.  The  differential  leucocyte  count 
was  negative.  The  pulse  was  115  to  120.  I  failed  to  make  a  blood  count. 
At  no  time  did  I  detect  the  temperature  lower  than  100°  or  the  pulse- rat «• 
less  than  102. 

"On  April  20,  I  advised  the  use  of  the  X-rays  and  gave  the  first 
exposure.  The  neck  measured  13 i  inches  over  the  most  prominent  por- 
tion. I  made  one  exposure  each  day,  of  a  duration  of  fifteen  to  twenty 
minutes.  After  the  exposure  on  the  second  day  the  patient  complained 
of  feeling  much  worse.  After  the  third  exposure  splenic  tenderness  was 
greatly  increased,  so  that  gentle  percussion  caused  considerable  pain. 

"April  24th  her  neck  measured  12V  inches  and  had  visibly  decreased 
in  size.  Two  days  later  it  measured  12  inches.  The  temperature  was 
103°,  the  pulse  115. 

"On  April  30  the  neck  measured  11 J  inches.  The  supraclavicular 
glands  were  much  shrunken  and  becoming  hard,  nodular,  and  more  freely 
movable  under  the  skin.  Temperature  was  100°,  pulse  100. 

"May  1  I  stopped  X-ray  treatment,  as  there  was  some  evidence  of 
dermatitis.  On  May  5,  temperature  was  98.4°  ;  pulse  100,  this  being  the 
first  time  I  found  temperature  normal  in  three  months'  observation. 

"May  12.  The  dermatitis  was  fully  developed  and  the  skin  was 
sloughing  in  some  places." 

Until  the  latter  part  of  July,  treatment  could  not  be  directed  to  the 
local  seat  of  disease,  because  of  the  derinatitic  area. 


THERAPEUTIC  VALUE  IX  DISEASE.  485 

"July  24  the  glands  were  still  receding,  and  the  neck  measured 
11  inches.  The  contour  fairly  matched  that  of  the  opposite  side.  She 
stated  that  she  felt  in  the  best  of  health,  and  her  appearance  fully  bore 
out  her  assertion. 

"  As  treatment  progressed,  the  spleen  increased  in  size.  This  phenom- 
enon was  also  noted  by  Senn,  but  I  have  not  seen  any  mention  of  the 
distinct  rise  in  temperature  after  each  treatment,  encountered  in  this 
case.  The  only  explanation  that  I  can  offer  is  that  there  must  have  beeu 
certain  toxic  products,  liberated  through  the  influence  of  the  X-rays, 
which  were  at  once  taken  up  by  the  circulation,  causing  also  the  acute 
exacerbations  of  ill  feeling  following  each  exposure.  This  condition  of 
elevated  temperature  and  ill  feeling  lasted  from  ten  to  fourteen  hours, 
and  was  so  severe  at  times  I  thought  of  abandoning  treatment  had  it 
not  been  for  the  steady  reduction  of  the  size  of  the  glands." 

In  my  own  cases,  however,  I  have  never  encountered  this  so-called 
auto-intoxication  resulting  from  irradiations.  It  would  seem  that  the 
subject  needs  much  further  investigation. 

At  a  meeting  of  the  Chicago  Medical  Society  held  January  25,  1905,1 
Drs.  Joseph  A.  Capps  and  Joseph  F.  Smith  reviewed  the  advancements 
made  in  the  treatment  of  lymphatic  leukaemia  with  the  X-rays. 

The  first  case  was  treated  by  Dr.  Pusey  for  one  month,  but  without 
improvement.  In  1903  Dr.  Nicholas  Senn  reported  a  case  of  leukaemia 
symptomatic-ally  cured.  The  patient  presented  the  typical  symptoms  of 
spleno-niyelogenous  leukaemia  and  had  been  ill  for  fourteen  mouths. 
Treatment  was  begun  daily,  and  was  given  every  other  day  through  the 
latter  part  of  January  and  during  February,  March,  April,  and  May  ;  at 
the  time  of  Senn's  last  observation  the  white  count  came  down  to  10,000 
and  the  spleen  was  almost  of  normal  size.  The  patient  felt  perfectly 
well,  but  died  later  with  symptoms  of  toxaemia.  Cases  of  lymphatic  leu- 
kaemia treated  by  Senu,  Churchill,  and  Pusey  died  within  seventeen 
mouths. 

The  authors  reported  three  cases  of  lymphatic  leukaemia  treated  by 
the  X-rays,  two  of  which  were  of  the  acute  form.  One  patient  died  in 
six  days,  and  the  other  in  ten  days.  Of  the  subacute  cases  there  were 
two.  While  the  X-ray  exerted  a  beneficial  effect,  it  did  not  control  the 
disease.  Better  results  were  obtained  in  treating  chronic  cases,  of  which 
the  authors  reported  three.  They  stated  that  patients  with  spleno- 
niyelogenous  leukaemia  should  receive  X-ray  treatment,  because  they  are 
greatly  benefited  thereby.  They  respond  more  slowly  than  do  patients 
with  chronic  lymphatic  leukaemia.  These  patients  feel  that  they  are 
cured,  but  in  the  light  of  cases  reported  as  symptomatically  cured,  some 
of  which  have  since  died,  physicians  must  not  be  too  sanguine  in  regard 
to  pronouncing  cures. 

1  Journal  of  the  American  Medical  Association,  February  10,  1905. 


486  ELECTRO-THERAPEUTICS. 

Arneth '  made  a  careful  study  of  the  blood  findings  after  exposure 
to  the  Rontgen  rays,  aud  analyzes  all  the  testimony  thus  far  offered.  His 
final  verdict  is  that  the  Routgeu  rays  have  an  undoubtedly  favorable 
action  in  leukaemia,  but  that  it  is  indirect.  They  do  not  cure  the  lesions, 
but  they  destroy  the  parasites  which  are  causing  the  lesions.  The  action 
of  the  Rontgen  rays  in  leukaemia  is  like  that  of  quinine  in  malaria.  Both 
cure  the  patient  by  killing  off  the  micro-organisms  causing  the  trouble. 
This  assumption  entails  the  necessity  for  more  thorough  and  more  gen- 
eral exposure  to  the  rays.  They  should  be  as  extensive  and  as  protracted 
as  possible,  to  seek  out  and  destroy  the  causal  germ  in  its  remotest 
lurking-places,  not  restricting  the  exposures,  as  in  the  past,  to  the  blood- 
forming  organs  alone.  This  conception  supplies,  for  the  first  time,  an 
etiological  treatment  for  leukaemia  and  one  that  is  proving  more  successful 
than  any  in  the  past. 

The  clinical  and  histologic  findings  in  leukaemia  after  Rontgen 
treatment  were  observed  by  Lessen  and  Morawitz.2  The  patient  was  a 
man  of  36,  previously  healthy,  with  inyeloid  leukaemia  for  two  or  three 
years  before  it  terminated  fatally.  Forty  Routgeu  exposures  were  made, 
but  did  not  seem  to  arrest  the  progress  of  the  disease  after  the  first 
transient  improvement.  The  composition  of  the  blood  and  the  blood 
findings  changed  under  the  exposures,  finally  presenting  the  picture 
accompanying  aplasia  of  the  blood-forming  organs,  and  the  anatomical 
findings  were  those  of  hypoplasia.  It  was  most  pronounced  in  the  bone- 
marrow,  but  was  also  unmistakable  in  the  spleen  and  lymph-glands.  It 
was  accompanied  by  pronounced  proliferation  of  the  interstitial  tissue. 
Lessen  and  Morawitz  are  inclined  to  regard  the  hypoplasia  as  favored  and 
possibly  originated  by  the  three  weeks  of  rather  intense  Routgeu  treat- 
ment given  in  this  case.  Of  7  leukaeinic  patients  treated  by  Rontgen  expos- 
ures, 3  were  materially  improved,  and  the  others  are  still  under  treatment, 
with  the  exception  of  the  fatal  case  mentioned  above.  In  one  case  of 
myeloid  leukaemia  the  leucocyte  formula  became  normal,  and  the  elimina- 
tion of  uric  acid  also  returned  to  normal  proportions.  This  suggests  an 
increased  new  formation  of  leucocytes  as  probable.  In  the  first  case 
with  extreme  leucopenia  the  amount  of  uric  acid  eliminated  remained 
abnormally  high  throughout. 

While  Drs.  David  L.  Edsall  and  ,T.  K.  Pancoast,  of  Philadelphia. 
believe  that  X-ray  treatment  of  leukaemia  is  unsatisfactory  because  of 
secondary  results,  Musser*  is  of  the  opinion  that  the  reason  for  this  is 
that  the  treatment  was  undertaken  in  old  cases  in  which  secondary 
changes  had  occurred  before  the  use  of  the  X-rays,  which  only  served  to 
stimulate  the  progress  of  such  changes.  In  one  case  of  his  own,  treated 

'Munch,  med.  Woch.,  August  22,  1905. 
*Deutsches  Archiv  f.  klinische  Medizin,  Leipaic. 
1  New  York  Medical  Journal,  April  7,  1906. 


THERAPEUTIC  VALUE  IX  DISEASE.  487 

by  the  X-rays,  there  had  been  an  entire  disappearance  of  the  leukaemia 
and  the  patient  had  been  restored  to  a  normal  condition  generally.  The 
leucocytes  had  been  reduced  from  6000  to  4000,  and  he  believed 
that  a  cure  had  been  effected.  At  the  same  time,  he  thought  it  would  be 
necessary  to  resort  to  the  X-rays  from  time  to  time  in  order  to  pre- 
vent a  recurrence  such  as  had  taken  place  in  another  case  which  he  had 
treated. 

IV.   Miscellaneous  Affections. 
A.  TRACHOMA. 

My  technic  in  treating  cases  of  trachoma  consists  in  covering  the 
Crookes  tube  with  a  dark  cloth,  excluding  all  light  from  the  room, 
because  of  the  excessive  photophobia.  With  adhesive  plaster  I  attach 
the  everted  eyelids  to  the  skin,  and  expose  the  surface  of  the  eye ;  thus 
preventing  burning  the  fingers  of  nurse  or  assistant.  I  cover  the  face 
with  a  leaden  sheet,  and  treat  one  eye  at  a  time,  through  an  aperture  in 
the  lead.  Rapidity  of  action  is  obtained  by  getting  the  patient  to 
keep  the  eye  open  while  under  treatment.  There  is  less  danger  of 
burn  to  the  cornea  than  there  is  to  the  skin  of  the  eyelid,  but,  should 
a  slight  corneal  haziness  result,  it  quickly  disappears,  and  the  corneal 
scar  will  be  absorbed.  I  had  two  acute  and  two  chronic  cases  of 
trachoma  at  the  Philadelphia  Hospital.  The  acute  cases  had  severe 
photophobia  and  lacryuiatiou,  which  disappeared  after  four  or  five 
exposures. 

Sydney  Stephenson  and  David  Walsh  l  report  the  results  of  treat- 
ment of  trachoma  or  granular  lids  by  the  X-rays  and  by  brush  discharges 
obtained  from  a  D' Arson  val  high-frequency  apparatus.  The  writers 
treated  a  single  eye  in  four  cases  of  severe  bilateral  trachoma  in  children. 
Two  eyes  were  cured,  that  is,  the  granulations  and  conjunctival  hyper- 
trophy disappeared,  and  have  not  returned  after  a  period  of  several 
mouths.  The  remaining  two  eyes  were  greatly  benefited  and  are  recov- 
ering. The  cures  were  effected  by  17  exposures  in  one  case  and  but  6  in 
the  other.  The  average  time  was  ten  minutes.  The  good  effects  were 
found  to  be  equally  marked  with  closed  as  with  everted  eyelids.  Twenty- 
two  applications  of  a  mild  high-frequency  brush,  using  a  vulcanite  elec- 
trode connected  with  a  D'Arsonval  apparatus,  cured  a  severe  case  of 
trachoma  in  another  patient. 

Radiotherapy  in  trachoma  presents  advantages  over  the  ordinary 
treatment  by  escharotics.  It  is  more  rapid  and  is  painless.  The  fact 
that  equally  good  results  were  obtained  with  an  active  focus  tube,  and  also 
by  a  high-frequency  brush  discharge,  suggests  that  the  curative  agency 
may  be  identical  in  both  instances. 

1  Lancet,  January  24  1903. 


4ss  ELECTRO-THERAPEUTICS. 

At  a  meeting  of  the  Philadelphia  County  Medical  Society,  Xovem- 
ber  23,  1904, l  Drs.  "W.  S.  Xewconiet  and  J.  P.  Krall  presented  a  girl  of 
18,  who  had  been  subjected  to  all  the  operations  for  the  cure  of  trachoma, 
without  success.  She  was  treated  with  the  X-rays  from  July,  1903,  until 
January  1,  1904.  The  inflammatory  reaction  was  so  intense  that  it  was 
thought  better  to  abandon  the  treatment.  Later,  however,  it  was  found 
that  she  could  count  fingers  at  close  range.  The  cornea  was  entirely 
clear,  and  only  with  special  illumination  could  there  be  seen  fine  blood- 
vessels. The  eye  not  treated  with  the  X-rays  showed  all  the  symptoms 
that  the  treated  eye  formerly  exhibited.  The  condition  of  the  patient 
had  been  present  since  infancy,  and  she  had  been  unable  to  see  across  the 
room.  Treatment  was  given  every  other  day  for  five  minutes  for  about 
six  weeks,  when  a  burn  developed  and  treatment  was  withheld.  Dr. 
Newcomet  believed  the  result  to  be  due  to  the  accidental  burn  produced 
in  the  course  of  treatment. 

Ruggero  Pardo J  describes  two  cases  of  trachoma  of  long  standing, 
rebellious  to  treatment.  Six  exposures,  with  a  total  of  44  minutes  in  one 
case  and  of  47  in  the  other,  caused  so  marked  an  improvement  that  a 
permanent  cure  is  anticipated.  The  tube  had  a  spark  length  of  2.5  to  2.7 
inches  (6.5  to  7  cm.),  the  distance  varied  from  12  to  15  inches  (30  to 
45  cm.),  the  applications  were  from  4  to  10  minutes  at  a  time,  and  only 
one  eye  was  treated  ;  the  eyeball  was  protected  by  a  sheet  of  lead  at  some 
of  the  stances. 

Geyser8  maintains  that  a  few  exposures,  six  to  eight,  will  suffice  to 
bring  about  a  perfect  cure.  An  important  consideration  is  to  cause 
absorption  and  stimulate  normal  nutritional  processes  ;  nothing  seems  to 
answer  the  purpose  any  better  than  the  direct  contact  of  the  tissues  with 
a  high-frequency  vacuum  tube,  generated  by  a  static  machine  or  X-ray 
coil.  Complete  details  of  technic  are  given  in  the  article. 

H.  X.  Bishop 4  gives  the  results  of  electrical  treatment  of  trachoma 
at  the  Middlesex  Hospital.  Cases  had  been  treated  with  well-equipped 
apparatus,  with  rays,  high-frequency  currents,  and  radium.  With  regard 
to  the  X-rays  he  explains  that  there  were  two  sets  of  rays  emanating 
from  the  tube,  (1)  the  X-rays  proper,  (2)  the  overflow  rays  that  cause 
the  severe  burning  of  the  skin  which  sometimes  occurred.  The  former 
of  these  rays  were  used.  Four  cases  of  trachoma  were  treated  in  this 
manner.  Two  were  young  women.  In  one,  fifty  applications  were  made 
in  five  months.  The  right  eye  showed  changes  that  might  reasonably 
have  been  produced  in  this  time  without  treatment,  while  the  left,  which 
was  at  first  unaffected,  steadily  got  bad.  The  disease  subsequently 

1  Journal  of  the  American  Medical  Association,  January  14,  1905. 
'Gazzetta  degli  Ospedali,  Milan,  last  indexed  xiii.,  p.  1193,  April  10, 1904. 

3  Journal  of  Advanced  Therapeutics,  May,  1904. 

4  British  Medical  Journal,  August  26,  1905. 


Fro.  234.— Tuberculosis  of  the  skin. 


FIG.  235.— The  same  after  irradiation. 


FIG.  236. 


FIG.  237. 


•Vi 


-  ''^;  1 

/Wfl 


Group8  of  patients  that  I  Irradiated  for  epilepsy  at  the  Philadelphia  Hospital.  Upper  two  rows 
(Figs.  236  and  237)  show  alopecia  iinxluciMl  by  X-rays  during  three  months  of  treatment  for  epilepsy. 
No.  8  on  the  second  row  was  not  thns  affected.  Fig.  238,  taken  six  months  later,  shows  the  regrowth 
of  the  hair.  No.  7  wns  previously  bald,  but  upon  application  of  th<-  rays  the  growth  of  hair  appeared. 


THERAPEUTIC  VALUE  IX  DISEASE.  489 

cleared  up  in  the  usual  manner  with  bluestone.  None  of  the  three  other 
cases  did  any  better.  The  seven  cases  treated  with  high-frequency 
currents  did  not  improve  at  all. 

Yassiatiiisky1  asserts  that  the  rays  diminished  the  infiltration  in 
trachoma,  caused  the  disappearance  of  the  granulations  and  of  the 
pannus,  and  produced  a  pronounced  improvement  in  the  subjective  signs 
of  the  malady.  As  a  rule,  however,  trachomatous  granulations  dis- 
appeared but  slowly  under  the  influence  of  the  Eontgen  therapy.  The 
rays  proved  to  be  harmless  in  treating  the  eyes,  and  no  evil  effects  were 
noted  in  any  case,  nor  was  pain  experienced  by  the  patients.  The  author 
thinks  that  the  rays  are  of  service  in  cases  in  which  ordinary  methods  of 
treatment  fail. 

I  treated  a  case  of  chronic  conjunctivitis  of  both  eyes  referred  to  me 
by  Dr.  T.  B.  Schneideman.  The  patient  had  been  a  sufferer  for  fifteen 
years.  I  exposed  the  eyes,  once  weekly,  to  the  action  of  the  rays.  The 
treatment  was  not  continuous,  as  I  feared  a  constant  and  frequent  appli- 
cation of  the  rays.  I  began  treatment  with  a  one-minute  exposure  twice 
weekly,  tube  fifteen  inches  from  the  part.  Within  two  years  sixty  appli- 
cations were  made.  The  first  fifteen  treatments  were  of  one  minute 
duration.  I  then  increased  treatments  gradually  up  to  five  minutes.  The 
conjunctivitis  is  practically  cured,  and  the  blood-vessels  of  the  part  have 
become  small  and  shrunken. 

B.  KELOID. 

Dr.  William  H.  Harsha5  reports  the  case  of  a  young  man,  eighteen 
years  of  age,  who  had  a  small  growth  behind  the  right  ear  for  ten  years 
that  microscopically  proved  to  be  a  keloid.  It  was  excised,  but  in  three 
or  four  months  the  tumor  was  as  large  as  ever.  X-ray  treatments 
were  then  begun  and  were  given  at  intervals  of  two  or  three  days, 
but  were  not  kept  up  regularly.  He  had  not  frequent  treatments  by 
the  X-rays  in  the  last  six  mouths.  The  growth  now  showed  not  more 
than  one-sixth  of  its  size  when  the  treatment  was  begun  and  it  was  still 
getting  smaller. 

Dr.  A.  J.  Ochsner  asserts  that  the  treatment  of  keloid  by  means  of 
the  X-rays  is  worthy  of  attention.  In  several  cases  the  improvement  was 
very  marked  after  operation  by  the  subsequent  X-ray  treatment.  He 
believes  that  before  removing  any  keloid  one  should  treat  it  thoroughly 
with  the  X-rays. 

Dr.  H.  K.  Varney3  reports  a  case  of  keloid  of  the  foot,  caused  by  pas- 
sage of  a  rifle-ball.  Eight  treatments  were  given ;  complete  disappear- 
ance of  the  keloid  with  development  of  normally  appearing  scar  tissue 

1  Roussky  Vratch,  January  8,  1905. 

z  Chicago  Surgical  Society,  December  7,  1903. 

s  The  International  Journal  of  Surgery,  October,  1903. 


490  ELECTRO-THERAPEUTICS. 

resulted.  The  patient  had  also  a  keloid  the  diameter  of  a  silver  dollar  at 
the  site  of  vaccination. 

Dr.  G.  P.  Edwards1  reports  three  cases  of  keloid  cured  with  the 
X-rays. 

Morris  and  Dore  *  report  that  they  have  treated  a  few  cases  of  keloid 
with  the  X-rays,  in  some  of  which  there  had  been  a  decided  increase  in 
the  growth.  Pain  was  in  all  cases  completely  relieved. 

Dr.  Henry  K.  Pancoast3  reported  two  cases  of  keloid  treated  by  the 
rays.  In  one  case  there  were  multiple  keloids  following  a  burn.  The 
other  patient  had  a  large  keloid  involving  the  ear,  neck,  and  angle  of  the 
jaw.  Both  patients  were  colored.  In  the  first  case  six  treatments  were 
given,  and  in  the  second  forty-three  treatments.  The  results  were  nega- 
tive, probably  because  the  treatments  were  not  pushed. 

Drs.  Fordyce,4  Fox,5  and  H.  R.  Barney6  report  favorable  results. 

Dr.  O.  S.  Barnum7  uses  an  abundance  of  rays  emanating  from  a  tube 
of  high  resistance  and  excited  by  a  large  coil.  He  believes  that  it  is 
better  to  have  the  tube  too  high  than  too  low.  The  tube's  distance  should 
be  fifteen  to  twenty  inches,  depending  on  the  thickness  of  the  tumor. 
The  thicker  the  tumor,  the  higher  the  tube,  the  greater  the  distance  and 
the  longer  the  exposure.  He  usually  exposes  the  growth  for  from  fifteen 
to  twenty-five  minutes  on  alternate  days  for  ten  days,  and  then  stops 
treatment  for  ten  days,  repeating  the  procedure  until  the  tumor  has  dis- 
appeared. He  has  had  excellent  results  in  the  treatment  of  keloids  by 
this  method. 

Drs.  Boggs,  Pancoast,  and  others  favor  preliminary  excision  of 
the  tumor,  whenever  this  is  possible,  following  this  with  Rontgeu  treat- 
ment. The  tumors  disappear  more  rapidly  and  are  not  so  liable  to  recur. 

C.  EXOPHTHALMIC  GOITRE. 

Dr.  Charles  H.  Mayo,8  in  a  paper  entitled  "  Thyroidectomy  for 
Exophthalmic  Goitre,"  says:  "It  has  been  our  fortune,  or  misfortune 
from  its  difficulties,  to  operate  on  several  cases  of  cervical  adenitis  which 
had  been  exposed  for  many  times  to  the  X-rays.  It  was  noted  that  the 
lymph  system  was  greatly  sclerosed.  As  this  was  in  line  with  the 
reported  action  of  the  X-rays  upon  glandular  activity,  we  applied  this 
treatment  to  ten  cases  of  very  marked  exophthalmic  goitre  during  the 

1  The  International  Journal  of  Surgery,  October,  1903. 

1  British  Medical  Journal,  June  16,  1903. 

s  Proceedings  of  the  Philadelphia  County  Medical  Society,  November  30,  1903. 

4  Journal  of  Cutaneous  Diseases,  April,  1904,  p.  187. 

5  Ibid.,  July,  1903,  p.  323. 

6  Journal  of  the  American  Med.  Association,  June  6,  1903. 
'Transactions  of  the  American  Rnntgen  Ray  Society,  1906. 
8  Medical  Record,  November  5, 1904. 


THKRAPK!  TI<     VAIJ'K   IX  DISEASK.  49L 

past  year,  to  first  reduce  glandular  activity,  and  second,  reduce  absorp- 
tion by  its  possible  effect  upon  the  lymphatics.  While  I  would  not 
as  yet  say  that  any  of  these  cases  are  cured,  they  have  certainly  been 
markedly  benefited  ;  first,  in  the  general  nervousness  ;  second,  in  tremor 
of  the  muscles  ;  third,  in  tachycardia  ;  and  last,  in  the  exophthalnios. 
The  benefit  is  sufficient  to  give  this  method  a  place  in  the  treatment  of 
Graves'  disease,  or  at  least  make  it  a  preparatory  treatment  to  a  prospec- 
tive surgical  method  at  a  later  period.  . 

"Our  rules,  concerning  the  cases  of  Graves'  disease  which  come  to  us 
for  operation,  are  to  operate,  if  their  condition  is  fair,  but  if  the  pulse  is 
from  130  to  160,  or  if  it  suddenly  fluctuates  in  tension  and  rapidity,  if 
there  is  anaemia,  with  swelling  of  the  feet,  the  patients  are  placed  upon 
the  belladonna  treatment  for  some  days.  The  more  severe  types  are  also 
given  X  ray  exposures  in  addition,  which  are  continued  from  two  to  six 
weeks." 

Gorl '  has  tried  radiotherapy  in  goitre  with  what  he  considers  very 
encouraging  results.  Seven  cases  were  treated,  and  in  all  there  was 
marked  diminution  in  the  size  of  the  growth,  as  well  as  improvement  in 
the  other  symptoms.  The  author  believes  that  it  is  primarily  the  paren- 
chyma cells  that  are  affected  by  the  rays,  and  not  the  blood-vessels,  as  the 
diminution  in  size  of  the  gland  begins  so  promptly  and  takes  place  so 
uniformly.  Medium  soft  or  soft  tubes  were  employed,  and  at  a  compara- 
tively short  distance  from  the  skin.  Care  is  necessary  to  prevent  burns  ; 
in  one  case  the  author  found  the  patient's  skin  was  unusually  sensitive  to 
the  rays,  and  he  suggests  that  this  condition  may  be  one  of  the  symptoms 
of  the  disease. 

G.  E.  Pfahler2  speaks  of  31  cases  that  he  collected,  with  an  im- 
provement in  28  of  them.  Stegmau3  speaks  most  favorably  of  X-ray 
treatment  in  35  of  his  goitrous  patients. 

Widerrnan4  has  noted  improvement  in  some  of  the  symptoms  in  his 
five  cases. 

Dock5  treated  32  patients  with  exophthalmic  goitre,  and  be  believes 
that  X-ray  treatment  is  only  an  adjunct  to  other  therapeutic  measures. 

Pfeiffer6  describes  his  experiences  with  Rontgen  treatment  of  goitre 
at  von  Bruns'  clinic  at  Tubingen.  The  particulars  of  51  cases  are  given 
and  the  histological  findings  in  8,  with  the  results  of  experimental  re- 
search. The  general  conclusion  is  to  the  effect,  that  Rontgeii  treatment 
of  goitre  is  ineffectual  as  a  rule  and  should  not  supplant  the  better-tried 
methods. 

• 

1  Munch,  rned.  Wochenschr. ,  vol.  Hi.,  Xo.  20. 
*  Therapeutic  Gazette,  March  15,  1906. 

3  La  Tribune  Medicale,  January  27,  1906. 

4  Ibid. 

5  American  Medicine,  February  24,  1906. 

'Beitriige  R.  klin.  Chirurg.  von  Bruns,  Tubingen,  p.  1149. 


492  BLBCTBO-THBBAPEUTICa 

Dr.  Charles  Lester  Leonard '  noticed  marked  improvement  in  four 
cases  of  goitre.  One  of  the  patients  has  had  no  recurrence  for  a  period 
of  three  years. 

Dr.  T.  V.  Crandall  had  a  patient,  aged  22.  suffering  with  a  unilat- 
eral goitre.  I  irradiated  the  tumor  twenty  times  within  sixty  days,  and 
the  goitre  became  markedly  decreased  in  size.  The  previous  nervous  dis- 
turbances at  once  abated.  I  believe  the  action  of  the  rays  in  these  cases 
is  quite  analogous  to  its  action  in  tuberculous  adenitis  and  other 
glandular  affections. 

D.  HYPERTROPHIED  PROSTATE. 

Carabelli  and  Luraschi 2  report  two  cases  of  hypertrophied  prostate 
treated  by  X-rays  after  one  year's  observation.  They  were  the  first  cases 
properly  treated  by  this  method.  The  patients  were  respectively  sixty 
and  sixty-five  years  of  age.  They  were  placed  on  a  sloping  table,  the  sur- 
rounding parts  carefully  protected,  and  the  Rontgen  rays  applied  to  the 
perineum,  with  the  tube  from  20  to  25  cm.  from  the  skin.  Carabelli  did 
not  think  it  necessary  to  introduce  a  tube  into  the  rectum,  as  the  atro- 
phying action  of  the  Rontgen  rays  on  deep-lying  glands,  like  the  ovary, 
spleen,  and  lymphatics,  had  been  amply  established.  It  is  evident,  also, 
that  the  action  of  the  rays  on  the  prostate  is  more  pronounced  when  the 
hypertrophy  is  in  the  first  stage.  The  relief  of  the  pain  was  marked 
from  the  very  first.  The  rays  were  applied  fifteen  times,  at  first  two  or 
three  times  per  week  and  then  once  a  fortnight.  The  sensory  symptoms 
vanished  and  urination  became  very  much  easier. 

In  the  second  case  the  prostate  was  much  enlarged  and  hard,  and 
there  were  about  200  gnu  of  residual  urine  and  evidences  of  chronic 
catarrh  of  the  bladder.  After  six  applications  of  the  X-rays,  the  urine 
became  clearer,  the  pain  subsided,  urination  was  much  easier,  and  the 
residual  urine  was  only  40  gm.  After  the  tenth  application,  there  wore 
only  10  c.c.  of  residual  urine,  and  the  patient  was  dismissed  as  practi- 
cally cured.  The  treatments  were  from  three  to  seven  minutes  in  the 
first  case  and  ten  minutes  in  the  second  ;  the  current  14  amperes  and  100 
volts.  After  one  year  the  results  are  permanent. 

In  view  of  the  fact  that  hypertrophied  prostate  in  most  instances  is 
due  to  a  glandular  proliferation,  and  therefore  contains  epithelial  ele- 
ments very  susceptible  to  the  Rontgen  rays,  Dr.  Moskowicz,  of  the 
Rudolph  Hospital,3  has  treated  a  number  of  cases  of  this  kind  by  radia- 
tion through  the  rectum.  After  a  few  treatments  the  patients  were  able 
to  urinate  spontaneously,  and  the  improvement  has  persisted.  Large 

1  New  York  Mc.liral  Journal,  April  21,  1906. 

<  ia/.zctta  dt-jfli  Osjiedali  Milano  and  abstracted  from  The  Jour,  of  the  Am.  Med. 
Asso.,  Sept.  2, 1905. 

'Semaine  Mi-dicale,  April  5,  1905. 


THERAPEUTIC  VALUE  IN  DISEASE.  493 

indurated  prostates  became  smaller  and  softer.  It  is  the  intention  of 
Dr.  Moskowicz  to  try  radium  in  other  cases,  as  being  more  suitable  and 
probably  more  efficient. 

i;.    ANALGESIC  ACTION  OF  THE  RAYS. 


.  —  It  would  seem  almost  a  certainty  that  the  X-rays  pos- 
sess an  analgesic  action.  In  carcinoma  the  pain  is  frequently  alleviated 
after  the  first  few  exposures.  The  analgesic  action  is  less  potent  in  deep- 
seated  cancers  than  in  superficial  ones.  Freund,  in  1899,  reported  that 
Grunmach  had  most  excellent  results  from  the  use  of  the  rays  in  neural- 
gia and  articular  rheumatism.  Gocht  found  marked  temporary  relief  in 
a  case  of  obstinate  trigeininal  neuralgia.  Dr.  William  M.  Sweet,1  of  Phil- 
adelphia, believes  that  X-rays  exert  a  peculiar  action  on  the  nerve  tissue, 
as  the  skin  after  intense  irradiation  becomes  quite  anaesthetic.  In  con- 
nection with  this  interesting  subject  are  appended  the  views  of  Dr. 
Charles  Lester  Leonard,  of  Philadelphia,2  who  reports  eight  cases,  six 
of  neuralgia,  one  of  neuritis,  and  one  of  scar  tissue  of  the  brain  follow- 
ing the  removal  of  a  cyst  from  the  motor  area  five  years  previously,  in 
which  the  Rdntgeu  rays  formed  the  principal  treatment. 

All  of  the  six  cases  of  neuralgia  were  due  to  impaired  metabolism 
of  the  nerve  tissue.  The  first  was  infra-  and  supraorbital  neuralgia  fol- 
lowing an  attack  of  influenza  ;  the  pain  was  relieved  by  the  first  treat- 
ment of  three  minutes  and  cured  permanently  by  four  more  such  treat- 
ments. The  second  was  a  severe  neuralgia  of  both  inferior  and  superior 
dental  nerves,  which  had  lasted  seven  months  and  was  accompanied  by 
loosening  of  the  teeth;  three  five-minute  applications  upon  each  side 
of  the  face  every  other  day  relieved  the  pain  entirely  ;  the  teeth 
resumed  their  proper  place,  and  at  the  end  of  eight  treatments  the  patient 
was  entirely  well.  He  has  remained  so  for  the  past  two  years. 

The  third  was  a  case  of  migraine  which  had  existed  for  ten  years, 
resisting  various  kinds  of  treatment.  The  first  application  lessened  the 
intensity  of  pain,  and  at  the  end  of  the  course  of  treatment  (number  of 
applications  not  stated)  she  was  entirely  cured. 

The  fourth  case  was  trigemiual  neuralgia  and  was  much  relieved, 
but  the  patient  discontinued  treatment  after  four  weeks  and  has  not  since 
l>een  heard  from. 

The  fifth  was  a  case  of  brachial  neuralgia  ;  this  patient  also  discon- 
tinued treatment  prematurely. 

The  sixth  was  a  case  of  severe  tic  douloureux  with  crises  almost 
every  five  minutes.  The  first  application  relieved  the  pain,  but  the 
patient  left  town  after  four  treatments,  promising  to  report  if  he  had 
any  further  attacks  ;  he  has  not  since  reported. 

1  American  Medicine,  Dec.  13.  1902. 
'Ibid.,  July  8,  1905. 


494  ELECTRO-THERAPEUTICS. 

The  case  of  neuritis  occurred  in  the  facial  nerve,  and  evidence  of  de- 
generation was  shown  by  areas  of  local  anaesthesia  over  its  entire  distribu- 
tion, the  point  of  most  intense  pain  being  over  the  inastoid  region  and  the 
posterior  surface  of  the  ear  in  the  distribution  of  the  posterior  auricular 
nerve.  This  patient  was  greatly  relieved,  but  not  eatirely  cured,  possibly 
because  the  treatments  were  not  applied  with  sufficient  regularity. 

The  patient  in  whom  it  was  attempted  to  produce  absorption  of  scar 
tissue  had  complete  paresis  of  the  right  arm,  with  glossy  skin  on  the 
fingers  and  absence  of  wrinkles  ;  the  arm  could  not  be  raised  voluntarily. 
Right  leg  was  also  somewhat  lame.  Slight  epileptiforni  attacks  which 
had  occurred  recently  were  attributed  to  a  recent  blow  upon  the  occiput. 
As  a  result  of  the  X-ray  applications  the  epileptiform  attacks  became 
less  severe  and  less  frequent,  and  the  patient  gradually  gained  control  of 
the  arm  and  hand,  so  that  he  could  raise  the  hand  to  his  head  and  mouth 
and  could  grasp  objects  of  moderate  size.  There  was  also  decided  improve- 
ment in  his  gait  and  speech.  He  received  12  applications  in  6  weeks,  the 
rays  being  applied  through  the  trephine-opening  in  the  skull.  As  the 
bromides  were  continued  in  increasing  doses  with  the  Routgen  applica- 
tions, it  is  considered  possible  that  the  results  cannot  be  attributed 
exclusively  to  the  rays. 

Leonard  appears  to  believe  that  successful  treatment  of  such  cases  is 
very  largely  dependent  upon  a  proper  technic. 

Haret1  treated  successfully  with  X-rays  an  obstinate  case  of  trigeni- 
inal  neuralgia  after  all  other  methods  had  proved  unavailing.  The  pain- 
ful region  was  irradiated  through  the  mouth,  the  neighboring  parts  be- 
ing protected  by  a  tube  of  lead  glass.  The  X-rays  were  directed  on  the 
alveolar  border  in  the  region  of  the  first  and  second  molar  teeth.  A  dose 
of  four  Holzknecht  units  was  given  daily,  using  rays  corresponding  to 
number  seven  or  eight  on  Benoist's  scale.  After  the  first  and  second 
stances  there  was  no  noticeable  change.  After  the  third  irradiation  the 
patient  asserted  that  there  was  some  diminution  of  the  pain.  There  \\  as 
slight  reaction  of  the  skin  on  the  border  of  the  upper  lip,  which  had  been 
imperfectly  shielded  from  the  rays.  After  the  fourth  stance  there  was  a 
complete  cessation  of  all  pain.  Since  then  the  patient  has  remained  free 
from  any  recurrence  of  the  affection. 

For  four  years  Faber's*  patient  had  suffered  from  trigeminal  neu- 
ralgia, with  two  intervals  of  a  few  month's  freedom  from  pain  after  oper- 
ation. As  the  neuralgia  recurred  with  increased  intensity  and  frequency, 
ten  Rontgen  exposures  of  ten  minutes  each  were  applied  to  the  upper 
half  of  the  face  within  sixteen  days.  Improvement  was  evident  at  once 
and  the  patient  was  soon  entirely  free  from  pain.  There  has  been  no 
recurrence  during  the  few  months  since. 

1  Archive's  of  the  Rontgen  Ray,  May,  1906. 

1  Hospitalstidende-Copenhagen,  last  indexed  page  813. 


THERAPEUTIC  VALUE  IX  DISKASK.  495 

Dr.  E.  B.  Bondurant1  reports  that  one  application  of  the  X-rays 
apparently  cured  facial  and  intercostal  neuralgia.  Dr.  S.  W.  Allen  re- 
ports several  cases  which  show  that  neuralgic  pains  ceased  even  when  the 
X-rays  were  used  for  making  the  diagnosis.  I  have  noticed  that  many 
cases  of  neuralgia  were  temporarily  cured  when  the  X-rays  were  used  for 
diagnosing  dental  conditions. 

F.  EPILEPSY. 

Four  years  ago  I  examined  a  boy's  skull  for  depressed  bone,  the  lad 
being  a  sufferer  from  epilepsy.  His  physician  informed  me  that  since  his 
X-ray  examination  there  was  a  complete  absence  of  epileptic  seizures ; 
this  suggested  the  treatment  of  epileptic  cases  by  the  X-rays. 

Two  years  ago,  through  the  courtesy  of  Dr.  W.  W.  Hawke,  Superin- 
tendent of  the  Insane  Department  of  the  Philadelphia  Hospital,  twelve 
patients  were  selected,  the  youngest  being  six  and  the  oldest  sixty,  the 
attacks  varying  from  a  very  mild  type  to  a  severe  epileptic  seizure.  (Figs. 
236,  237.) 

X-ray  treatments  began  in  February,  March,  and  April,  1904  ;  treat- 
ment three  times  a  week,  exposures  five  minutes,  distance  of  the.  anode 
8-10  inches  (20  to  25  cm.).  Various  parts  of  the  skull  were  exposed. 
After  two  months'  treatment  alopecia  was  produced. 

The  results  and  improvements  from  the  X-ray  treatment  were  quite 
satisfactory,  as  will  be  noticed  from  the  lower  group  of  photographs. 
(Fig.  238.) 

The  following  table  exhibits  the  number  of  attacks  in  1903  and  1904, 
showing  the  improvement  due  to  the  rays  : 

CASES.  RESULTS. 

I.  Number  of  attacks  in  1903  were    68. 

Number  of  attacks  in  1904  were    41.     Decrease  of  27. 

II.  Number  of  attacks  in  1903  were  845. 

Number  of  attacks  in  1904  were  412.     Decrease  of  433. 
Nti  attacks  during  October,  November,  December. 

III.  Number  of  attacks  in  1903  were    59. 

Number  of  attacks  in  1904  Avere    14.     Decrease  of  45. 

Attacks  ceased  two  months  after  treatment,  but  patient  died  on  May  7,  1904. 

IV.  Number  of  attacks  in  1903  were    85. 

Number  of  attacks  in  1904  were    80.     Decrease  of  5. 

Patient  died  five  months  after  the  beginning  of  the  treatment. 

V.  Number  of  attacks  in  1903  were  144. 

Number  of  attacks  in  1904  were  120.     Decrease  of  24. 
No  attacks  during  October,  November,  December. 

1  New  York  Med.  Jour.,  August,  1902,  vol.  Ixxvi.  pp.  194-196. 


496  ELK(  TH(  )-THERAPEUTICS. 

VI.  Number  of  attacks  in  1903  were  209. 

Number  of  attacks  in  1904  were  191.     Decrease  of  18. 
No  attacks  during  October,  November,  December. 

VII.  Number  of  attacks  in  1903  were    69. 

Number  of  attacks  in  1904  were      4  during  the  same  months. 

VIII.  Number  of  attacks  in  1900  were      6. 
Since  then  no  attacks. 

IX    Number  of  attacks  in  1903  were  148. 

Number  of  attacks  in  1904  were  164.     An  increase  of  16. 

Number  of  attacks  increased  during  the  treatments,  but  during  October, 
November,  December,  there  were  no  attacks. 

X.  Number  of  attacks  in  1903  were    61. 

Number  of  attacks  in  1904  were    77.    Increase  of  16. 
Increased  during  the  treatment. 

These  results  of  X-ray  treatment  of  epileptics,  I  believe,  are  encour- 
aging when  we  notice  the  decrease  in  the  number,  duration,  and  severity 
of  the  attacks.  I  cannot  think  that  any  harm  can  be  done,  except  the 
alopecia  that  may  be  produced. 

The  sudden  death  of  two  young  patients  during  and  immediately 
after  the  treatment  was  not  the  direct  result  of  the  X-ray  treatment, 
although  the  autopsy  showed  congestion  of  the  brain,  which  might  have 
been  due  to  some  other  cause. 

Horace  Manders l  states  that  it  is  only  two  or  three  years  since  Branth 
conceived  the  idea  of  using  the  X-rays  for  the  relief  of  epilepsy,  on  the 
theory  that  these  rays  stimulate  protoplasm  into  greater  vital  activity. 
He  gave  three  treatments  a  week,  beginning  with  five  minutes'  exposure 
at  15  inches  distance,  and  increased  to  ten  minutes'  exposure  at  10  inches 
distance.  A  different  part  of  the  skull  was  exposed  at  each  sitting.  A 
hard  or  high-vacuum  tube,  backing  up  a  spark-gap  of  5  to  8  inches,  was 
used.  One  objection  to  this  treatment  is  the  alopecia  which  follows  it, 
but  the  hair  will  return  in  a  stronger  growth  than  before.  It  may  also 
be  desirable  to  continue  the  use  of  the  bromide  with  the  X-rays.  This 
treatment  is  usually  followed  by  a  gain  in  weight,  by  improvement  in 
enunciation  (if  that  were  faulty),  and  by  lighter  seizures  of  shorter  dura- 
tion and  at  longer  intervals.  This  treatment  is  not  available  if 
degenerative  processes  of  the  brain  have  begun. 

Dr.  J.  H.  Branth1  gives  three  treatments  a  week,  beginning  with 
5-minute  exposures  at  15  inches  distance,  and  by  degrees  increases  to  10 
minutes  at  10  inches.  A  different  part  of  the  skull  was  exposed  at  each 
sitting,  and  a  tube  of  high  penetration  used.  The  hair  drops  off  usually 
near  the  parts  exposed,  but  returns  later  in  stronger  growth.  In  some 

1  Archives  of  the  Rontgen  Ray,  April,  1905. 
*New  York  Medical  Journal,  June  11,  1904. 


THERAPEUTIC  VALUE  IN  DISEASE.  497 

cases  the  bromides  can  be  dispensed  with  ;  in  others,  small  doses  prove 
beneficial.  In  young  subjects  a  gain  of  weight  soon  results,  and  a  marked 
improvement  in  the  mental  faculties  takes  place.  The  impediment  in 
speech,  which  occurs  in  severe  cases  of  long  standing,  has  been  removed 
by  raying,  and  the  attacks,  which  numbered  from  6  to  10  a  day,  were 
reduced  to  one  every  2  or  3  weeks. 

It  is  to  be  hoped  that  these  results  will  be  confirmed  by  others.  1 
recall  a  case  where  I  took  two  radiographs  of  the  head,  with  a  view  of 
locating  the  cause  of  the  seizures.  The  patient  had  no  attacks  for  over 
two  months  following  the  exposures. 


CHAPTER  VI 
RADIUM  AND  OTHEE  EADIO-ACTIVE  SUBSTANCES. 

THE  remarkable  chemical  body  radium,  discovered  some  years  ago 
by  Prof,  and  Madame  Curie,  belongs  to  the  alkaline  group  of  elements. 
Madame  Curie  makes  the  atomic  weight  225.  We  know  that  barium  has 
an  atomic  weight  of  136.4  and  thorium  230.8 ;  thus,  according  to  the 
periodic  law  of  atomic  weights,  first  outlined  by  Mendeleeff,  radium  would 
stand  between  the  two  just  mentioned.  Demarcay  first  demonstrated 
that  radium  was  an  element,  being  characterized  by  a  spark  spectrum  of 
14  or  15  lines. 

OCCURRENCE. 

Radium  is  a  very  rare  element  and  has  for  its  source  ordinary  pitch- 
blende, occasionally  spoken  of  as  uranium.  An  abundance  of  this 
mineral  is  found  in  various  parts  of  the  world,  chiefly  in(Cormvall. 
Colorado,  Nevada,  Saxony,  Bohemia,  and  Thibet. 

Pitch-blende  is  a  mineral  of  a  "pitchy"  appearance  ;  chemically,  it 
consists  of  the  double  oxides  of  uranium,  the  oxides  of  lead  and  zinc,  in 
combination  with  more  or  less  rare  and  peculiar  metallic  bodies  in  smaller 
quantities.  Uranium,  a  commonly  used  body,  the  salts  of  which  are  of 
beautiful  tints  on  the  border  of  yellow,  has  been  for  years  extracted  from 
pitch-blende.  What  was  formerly  cast  off  as  the  useless  substance  of 
pitch-blende  is  to-day  saved  for  the  purpose  of  extracting  therefrom 
radium,  helium,  etc. 

CHEMICAL  AND  PHOTOGRAPHIC  EFFECTS. 

Professor  Henri  Becquerel,  a  noted  French  physicist  and  chemist, 
learned  that  the  compound  potassio- sulphate  of  uranium  was  endowed 
with  properties  similar  to  those  manifested  by  zinc  sulphide  and  other 
bodies.  He  discovered  that  when  uranium  or  any  of  its  salts  was 
exposed  to  helious  radiations,  they  became  endowed  with  the  faculty 
of  absorbing  the  rays,  which  in  turn  could  be  induced  to  act  upon  the 
film  of  a  sensitive  photographic  plate.  That  this  phenomenon  was  dis- 
played by  metallic  uranium  caused  him  to  believe  that  the  same  result 
might  take  place  if  he  used  the  ore  from  which  it  was  derived  primarily. 
Following  this  line  of  reasoning,  he  employed  ordinary  ore  (pitch-blende), 
desiring  to  influence  a  sensitive  plate  by  exposing  the  complex  ore  to  the 
rays  of  the  sun.  The  sun  was  obscured  by  clouds  ;  so  he  removed  the 
ore,  also  a  key  (that  he  desired  to  image),  and  the  sensitive  plate  to  a 
KM 


RADIUM  AND  OTHER  SUBSTANCES.  499 

closet,  intending  to  conduct  the  experiment  at  some  future  day.  Fortu- 
nately for  science,  he  forgot  the  experiment  for  several  days,  and,  upon 
examining  the  plate  after  developing,  he  observed  that  the  image  of  the 
key  had  already  been  imprinted  into  the  sensitive  coating  of  the  pitch- 
blende. Thus,  accidentally,  he  discovered  that  uranium  ore,  the  pure 
metal  and  also  its  salts,  would  cast  an  image  on  a  plate,  and  that  a  previ- 
ous exposure  to  sunlight  was  not  essential  to  the  evolution  of  these  dark, 
invisible  rays.  Even  though  a  uranium  salt  be  crystallized  out  of  its 
solution  in  the  dark,  and  allowed  to  remain  there,  it  still  possesses  the 
property  of  emitting  rays  which  affect  ordinary  photographic  plates. 

Photographic  paper  becomes  brittle  after  prolonged  exposure.  Ozone 
is  formed  in  the  air  about  radium.  The  rays  are  not  affected  by  the 
t-xtiviiH'S  of  temperature. 

Like  Elster  and  Geitel,  who  observed  that  certain  substances  which 
had  been  exposed  to  light  emitted  radiations  capable  of  discharging 
nt -Datively  electrified  bodies,  Becquerel  observed  the  same  quality  in  the 
radiations  that  bear  his  name. 

Sir  William  Crookes,  soon  after  the  discovery  was  made  public, 
subjected  the  salts  of  uranium  to  a  close  examination,  and  he  theo- 
rized that  these  radiations  were  not  due  to  the  uranium  itself,  but  to 
contained  impurities  in  the  salt.  He  crystallized  repeatedly  the  sub- 
stances, exercising  care  to  separate  the  crystals  into  two  portions, — on 
one  side  he  placed  those  crystals  which  formed  with  greater  ease,  and  on 
the  other  those  which  formed  slowly.  He  observed  that  one  set  of  crys- 
tals possessed  the  power  of  readily  emitting  raj  s, — i.e.,  they  were  said 
to  be  radio-active, — while  the  other  lot  of  crystals  were  devoid  of  such 
phenomenal  activity. 

At  the  outset  Professor  and  Madame  Curie  reasoned,  and  correctly 
so,  that  the  largest  percentage  of  the  radio-active  substance,  as  yet 
unknown,  was  found  in  the  ore  (pitch-blende)  and  not  in  uranium.  They 
undertook  the  task  of  extracting  the  unknown  body  from  the  ore,  and 
they  discovered  that  they  had  now  to  deal  with  two  distinctly  different 
bodies,  the  one  substance  was  that  which  gave  off  the  Becquerel  rays, 
and  the  other,  since  those  days,  has  been  termed  radium,  actinium,  and 
polonium.  Radium  is  present  in  pitch-blende  in  larger  quantities  than 
any  of  the  other  radio-active  substances. 

After  the  oxides  of  uranium  have  been  separated  from  the  ore,  the 
residue  remaining  behind  constitutes  little  more  than  three- quarters  of 
its  weight.  This  residue  contains  all  the  other  metals  entering  into  its 
complex  construction,  and  from  these  the  newer  radio-active  substances 
have  to  be  separated,  requiring  severest  attention.  Thorium,  one  of  the 
radio-active  elements,  extracted  from  the  refuse  ore,  is  not  new  ;  having 
been  known  by  chemists  for  years.  Polonium  is  contained  in  the  ore  in 
only  the  minutest  quantities.  Prof.  Markwald  was  able  to  extract  only 
15/100  of  a  grain  of  this  element  from  two  tons  of  refuse  ore,  from  which 


500  ELECTRO-THERAPEUTICS. 

uranium  oxides  had  been  extracted.  It  seems  to  be  somewhat  related  to 
bismuth.  Radium  usually  accompanies  the  barium  obtained  from  pitch- 
blende ;  it  resembles  it  in  its  reactions,  and  is  separated  from  barium  by 
the  differences  of  the  solubility  of  the  chlorides  iu  water  or  alcohol  con- 
taining hydrochloric  acid.  Radium,  in  the  metallic  or  pure  state,  has 
not  up  to  the  present  time  been  isolated.  It  could,  however,  be  isolated 
with  practically  no  difficulty  whatever,  according  to  the  opinion  of  Prof. 
Curie,  by  carefully  treating  the  chloride  part  of  the  salt  with  sodium 
or  potassium,  forming  a  chloride  salt  of  either  one  or  both  of  the  latter 
substances. 

PHYSICAL  PROPERTIES  OF  RADIUM. 

Radium  appears  like  ordinary  table  salt,  with  a  slightly  yellowish 
tinge.  It  is  weighty  and  non- deliquescent.  It  continuously  emits  a 
feeble  light,  which  is  only  recognizable  in  a  darkened  room.  All  the 
bodies  coming  in  combination  (or  otherwise)  with  radium  have  imparted 
to  them  radiations,  which  are  in  turn  given  off.  Zinc-blende  is  especially 
able  to  take  up  these  radiations.  Radium  also  constantly  gives  off  heat 
rays,  so  that  the  temperature  is  always  1.5°  C.  above  that  of  surrounding 
objects.  The  view  that  the  ray  and  heat  emanations  from  a  radium  salt 
do  not  cause  a  decrease  or  loss  on  the  part  of  the  salt,  is  incorrect,  the 
opposite  being  the  case  ;  although  we  must  bear  in  mind  that  this  loss  is 
very  minute. 

Penetration.  —  These  rays,  like  the  Rontgen  emanations,  traverse 
wood  and  the  lighter  metals.  By  placing  an  aluminium  disk  on  a 
black  paper  envelope,  covering  this  with  a  card,  over  which  are 
sprinkled  crystals  of  the  double  sulphate  of  potassium  and  uranium 
that  had  never  been  exposed  to  light,  Becquerel  was  able  to  obtain  a 
radiograph. 

Fluorescence  and  Luminosity. — This  is  well  illustrated  by  the  spin- 
thariscope of  Crookes.  This  consists  of  a  brass  tube,  having  at  one  end 
a  fluorescent  screen  and  in  front  of  this  a  little  movable  arrow.  On  the 
under  surface  of  the  tip  of  the  arrow,  that  is  just  opposite  the  screen,  is 
a  minute  particle  of  radium.  At  the  opposite  end  of  the  tube  is  an 
adjustable  lens.  Upon  going  into  a  dark  room  and  adjusting  the  lens  to 
suit  the  eye,  one  can  see  minute  particles  of  light  flying  off  from  the 
screen  in  every  direction,  and  dancing  around  at  a  rapid  rate,  suggesting 
a  shower  of  shooting  stars.  Slight  phosphorescence  is  also  produced  by 
radium. 

Greef  discusses  the  fact  that  the  rays  of  radium  are  visible  to  the 
naked  eye  in  the  dark.  It  is  not  a  phosphorescence,  as  radium  maintains 
this  property  indefinitely  when  kept  exclusively  in  the  dark  without 
exposure  to  any  light  It  induces  fluorescence  in  other  objects,  and  also 
emits  the  radium  rays  proper. 


KADI  I'M  AXD  OTHER  SUBSTANCES.  501 

THEORETICAL  CONSIDERATIONS  :   CLASSIFICATION  OF  THE  BAYS. 

What  are  the  emanations  (radiations)  from  radio-active  bodies  ?  Like 
the  problem  with  the  Routgen  rays,  the  very  same  state  of  affairs  exists, 
and  is  yet  to  be  solved  in  so  far  as  radium  and  associated  radio-active 
bodies  are  concerned.  A  number  of  authorities  are  of  the  opinion  that 
the  radiations  are  minute  particles  given  off,  and  not  the  undulations  in 
the  surrounding  medium  (ether). 

Crookes  speaks  of  three  kinds  of  radiations :  Similar  or  identical 
with  the  cathodic  emanations,  free  electrodes,  or  matter  in  the  ultra- 
gaseous  existence.  Distinct  atoms,  electrified  positively,  the  air  being 
rendered  a  conducting  medium,  and  affecting  photographic  plates.  Rays 
of  a  very  high  degree  of  penetration  accompanying  the  others  ;  Crookes 
believing  them  to  be  identified  with  the  X-rays. 

Taking  the  first  group,  we  may  state  that  the  rays  are  strongly  devi- 
ated in  a  magnetic  field,  the  second  rather  slightly,  and  the  third  not  at  all. 
They  all  produce  effects  on  photographic  plates,  and  excite  phosphores- 
cent bodies,  though  all  with  variable  differences.  The  former  and  the  lat- 
ter affect  strongly  platino-barium  cyanide  ;  the  second  have  no  such  effect. 

Some  speak  of  three  kinds  of  radio-activity  :  alpha,  beta,  and  gamma. 
The  alpha  rays  are  easily  absorbed  and  carry  a  positive  electrification  ; 
the  beta  rays  easily  penetrate  solids,  and  carry  a  negative  charge ;  and 
the  gamma  rays  have  a  very  intense  penetrative  power,  but  carry  no 
charge.  Some  state  that  the  gamma  and  the  Rontgen  rays  are  identical, 
though  Strutt,  of  Cambridge,  is  of  the  opinion  that  there  is  a  vast  differ- 
ence. Crookes  maintains  that  they  are  actual  emanations, — the  projec- 
tion of  minute  particles  from  the  radio-active  body  into  adjacent  space. 

Rutherford  asserts  that  if  the  radiant  particles  were  ejected  with 
slightly  less  velocity,  they  would  neither  ionize  the  air,  affect  a  photo- 
graphic plate,  nor  cause  fluorescence  ;  in  truth,  there  would  be  absolutely 
no  effect  capable  of  detection  by  our  apparatus. 

BIOLOGICAL  EFFECTS. 

Bactericidal  Action. — Crookes  exhibited  a  number  of  plate  cultures 
and  photographs  illustrative  of  the  bactericidal  properties  of  the  ema- 
nations from  radium.  Various  cultures  of  bacteria  were  exposed  to  the 
action  of  ten  milligrammes  of  bromide  of  radium,  through  a  mica  screen, 
at  a  distance  of  one  inch  from  the  surface  of  the  plate.  After  having  been 
subjected  to  the  action  of  the  radium  emanations,  the  plates  were  incu- 
bated for  24,  48,  or  more  hours.  In  every  case  it  was  found  that  the  mi- 
crobes were  killed  where  they  had  been  exposed  to  radium,  so  that  on 
incubation,  a  bare  space,  free  from  bacterial  growths,  was  left  on  the 
plate  opposite  the  point  where  the  radium  had  been  placed.  Among 
the  bacteria  experimented  upon  were  the  bacillus  coli  communis,  the 
bacillus  prodigiosus,  etc. 


502  ELECTRO-THERAPEUTICS. 

The  Ji(thicitr,<  of  Uadium  on  At/'/lnfimition.  — P.  P.  Jagn l  tested  the 
effect  of  radium  ou  the  specific  properties  of  blood  serum  in  typhoid  fever. 
It  was  found  that  after  an  exposure  of  the  typhoid  blood  serum  to 
radium  bromide,  lasting  2  or  3  days,  the  serum  completely  lost  its  agglu- 
tinating  properties.  An  exposure  of  shorter  duration  does  not  destroy 
the  agglutinating  power,  though  the  latter  undergoes  a  considerable 
reduction.  These  phenomena  the  author  is  inclined  to  attribute  to  the 
so-called  "beta  rays." 

Frederick  Soddy l  states  that  five  minutes'  application  of  radium  is 
equivalent  to  ten  years'  application  of  thorium,  although  both  instanta- 
neously produce  radio-active  emanations  of  gases  in  infinitesimal  quanti- 
ties. He  believes  it  possible  to  inhale  the  emanations  of  both  tlnise 
substances  in  the  treatment  of  pulmonary  tuberculosis.  The  maximum 
dose  of  radium  solution  should  be  the  gaseous  contents  of  a  bubble ;  a 
few  bubbles  every  24  hours. 

Physiological  Action. — Heineke3  believes  that  the  action  of  radium 
rays  is  approximately  the  same  as  that  of  the*  Rontgeu  rays.  Lymphoid 
tissue  is  affected  in  the  same  way,  but  not  to  the  same  extent  as  with  the 
Rontgeu  rays,  unless  the  radium  is  brought  into  close  contact,  when  a 
brief  exposure  will  astonishingly  induce  extensive  changes  in  the 
lymphoid  tissue,  apparent  in  a  few  hours. 

Effects  on  the  Nervous  System. — The  effects  on  the  nervous  system  are 
interesting  and  have  been  chiefly  studied  in  young  mice.  London  found 
that  mice  exposed  to  a  strong  preparation  of  radium  were  killed.  There 
was  first  redness  of  the  ears,  then  blinking  of  the  eyelids,  then  drowsi- 
ness, slowness  of  movement  and  feeble  response  to  stimuli.  This  was 
followed  by  paralysis,  then  coma,  and  finally  death.  The  symptoms 
developed  about  the  third  day  of  exposure,  and  the  animals  died  on  the 
fourth  or  fifth  day.  Along  with  these  nervous  symptoms  were  well 
marked  effects  on  the  skin.  The  hair  and  epidermis  were  loosened  and 
the  subcutaneous  tissue  was  greatly  congested. 

Effects  on  the  Eye. — Radium  produces  luminous  effects  on  the  retina 
even  when  the  eyes  are  closed.  This  is  due  either  to  fluorescence  of  the 
tissues  of  the  eye,  or  to  direct  effect  on  the  optic  nerves,  probably  the 
former.  This  effect  has  been  taken  advantage  of  by  Javal,4  London,  and 
others,  in  experimenting  on  the  blind  with  radium.  In  his  experiments 
.Javal  found,  in  two  cases  of  blindness  in  which  there  still  remained  a 
slight  perception  of  light,  that  the  patients  perceived  a  light  sensation 
when  radium  was  held  before  the  eyes.  In  two  other  cases  of  blindness, 
one  due  to  optic  atrophy,  and  the  other  to  glaucoma,  both  patients  being 
absolutely  blind,  there  was  no  perception  of  light  from  exposure  to 

1  Roussky  Vratch,  December  6,  1903. 
*  Nature,  vol.  78,  July  25,  1904,  p.  266. 

3  Miinchener  med.  Wochensrhrift,  vol.  li.,  No.  31,  1904. 

4  Physikal.  Zeitechr..  1900,  i.  p.  476. 


EADIUM  AND  OTHER  SUBSTANCES.  503 

radium.  London's  results  are  to  the  same  effect.  Blind  patients  who 
still  retained  a  slight  perception  of  light  were  cognizant  of  a  visual  sensa- 
tion when  radium  was  applied  to  their  eyes.  In  those  totally  blind  the 
results  were  negative. 

RADIUM  AND  THORIUM  AS  THERAPEUTIC  AGENTS. 

The  attention  of  the  medical  world  is  at  present  directed  to  the 
therapeutic  experiments  with  radium,  and  so  far  the  results  lead  us  to 
hope  that  it  will  prove  of  value  in  the  treatment  of  certain  skin 
diseases  and  malignant  conditions.  It  is  still  too  soon  to  pronounce 
authoritatively  upon  the  permanency  of  the  cure  in  malignant  cases. 
Already  many  instances  are  recorded  in  which  the  use  of  radium  has 
effected  complete  disappearance  of  carcinomatous  growths,  especially 
the  epitheliomata. 

Radium  does  not  give  so  good  a  differentiation  of  the  tissues  as  can 
be  obtained  by  the  X-rays,  it  is  of  little  value  in  taking  radiographs  or 
in  making  examinations  with  the  fluorescent  screen ;  but  on  the  other 
hand,  radium  is  far  more  convenient ;  it  can  be  easily  transported,  and 
can  be  applied  in  positions  difficult  of  access  with  the  X-rays,  and  its 
action  can  be  readily  controlled.  It  is  not  so  convenient  as  the  X-rays 
when  large  surfaces  require  treatment,  but  this  objection  may  be  over- 
come by  the  fact  that  the  emanations  from  radium  salts  which  will  pass 
through  the  air,  but  not  through  glass,  are  taken  up  by  rubber  and 
other  articles.  The  absorbed  rays  are  given  off  slowly  from  the  articles, 
and  apparently  have  the  same  effect  as  those  directly  derived  from  the 
radium  salts.  Williams1  remarks  that  his  clinical  results  with  the  beta 
rays  have  been  very  good,  and  he  is  now  trying  the  effect  of  the  gamma 
rays  upon  deep-seated  growths. 

The  gamma  rays  are  the  fewest  in  number,  but  are  deeply  pene- 
trating ;  the  beta  rays  are  more  numerous,  but  act  very  superficially, 
and  are  probably  instrumental  in  causing  the  burns  that  have  been  re- 
corded. The  action  of  the  gamma  rays  alone  can  be  obtained  by  inter- 
posing an  aluminium  screen,  which  intercepts  the  beta  rays,  but  allows 
the  gamma  rays  to  pass  through,  if  the  screen  be  not  too  thick. 

Diseases  of  the  Skin. — Scholtz2  has  been  testing  25  nig.  of  radium  bro- 
mide in  the  treatment  of  various  skin  affections  and  in  tumors,  and  in 
conducting  experiments  on  animals.  The  treatment  proved  particularly 
effective  in  lupus  and  superficial  cancer.  The  results  indicate  that 
radium  rays  produce  effects  closely  similar  to  those  of  the  X-rays.  The 
radium  can  easily  be  introduced  into  the  mouth,  nose,  throat,  and  vagina. 

F.  Williams3  bases  his  conclusions  on  the  study  of  fifty  cases  of 

1  Medical  News,  February  6,  1904. 

1  Deutsche  med.  Wochenschr.,  vol.  xxx.,  No.  24. 

s  Boston  Medical  and  Surgical  Journal,  Feb.  25,  1904. 


504  ELECTRO-THERAPEUTICS. 

various  diseases,  treated  with  radium  bromide,  in  quantity  about  50 
milligrammes,  aud  of  a  radio-activity  of  about  1,500,000.  The  author 
presents  the  following  summary  of  his  observations  : 

"1.  The  rays  from  radium  salts,  unlike  the  X-rays,  are  not  service- 
able in  diagnosis,  either  by  means  of  radiographs  or  of  fluoroscopic 
examinations.  2.  The  beta  rays  are  useful  as  a  therapeutic  agent  in 
certain  skin  diseases  and  new  growths,  if  the  diseased  tissues  are  super- 
ficial or  are  not  more  than  about  1.25  cm.  (1-2  an  inch)  below  the  surface 
of  the  skin  or  accessible  mucous  membranes.  3.  The  beta  rays  from 
radium  salts  will  heal  some  cases  of  new  growths  that  are  not  healed  by 
the  X-rays,  and  they  act  more  promptly,  but  not  over  so  large  a  surface 
at  one  time  as  do  the  X-rays.  4.  Radium  salts  of  an  activity  of  8000, 
or  considerably  more,  are  not  sufficiently  strong  to  be  efficient.  Pure 
radium  salts,  which  have  a  radio-activity  of  about  1,500,000,  are  not  too 
strong  for  the  work  to  be  done.  5.  The  radiation  from  radium  salts, 
unlike  that  from  the  X-ray  tube,  is  uniform.  6.  Great  care  should  be 
exercised  to  avoid  burns." 

Dr.  Meyer  and  William  J.  Hammer  treated  favorably  a  large  axil- 
lary cancer  with  radium  of  300,000  activity.  The  exposure  was  one 
minute  daily.  While  this  case  was  incurable,  the  cancer  grew  smaller 
and  less  painful  under  the  rays. 

Lovell  Drage '  believes  that,  in  cancer,  radium  first  produces  a  leuco- 
cytosis,  and  then  a  fibrosis.  In  the  case  of  pulmonary  tuberculosis  there 
is  no  difficulty  in  producing  these  conditions ;  in  that  of  cancer  much 
greater  difficulty  is  experienced  in  advanced  cases  than  is  the  case  with 
tuberculosis. 

Professor  Havas  observed  a  necrosis  after  the  application  of  radium 
to  a  mevus  piginentosus,  and  considered  its  action  similar  to  that  of  the 
Rontgen  rays. 

Mode  of  Retrogression  of  Cancer  Metastases  under  Radium  Rays. — Exner 
was  able  to  trace  histologically  the  retrogression  of  carcinomatous  nod- 
ules in  the  mamma  in  one  out  of  the  two  cases  described.  The  findings 
were  controlled  by  histological  examination  of  excised,  non-exposed  nod- 
ules. He  found  that  exposure  for  a  single  half  hour  was  able  to  induce 
complete  retrogression  of  a  nodule.  The  retrogression  was  complete  in 
five  weeks.  The  most  remarkable  feature  of  the  phenomenon  is  that  while 
the  cancer  cells  retrogress,  none  of  the  other  cutaneous  elements  was  de- 
stroyed. Within  a  week  of  the  exposure  there  was  a  new  formation  of 
connective  tissue,  while  at  this  time  the  cancer  cells  showed  no  change. 
There  are  numerous  new  formed  capillaries  in  the  new  connective  tissue. 
No  change  appears  in  the  cancer  cells  until  two  weeks  have  elapsed.  The 
rapid  proliferation  of  connective  tissue  seems  to  diverge  the  cancer  cells 
and  overwhelm  them  by  its  growth,  actually  squeezing  them  to  death. 

1  British  Medical  Journal,  December  12,  1904. 


RADIUM  AXD  OTHER  SUBSTANCES.  505 

Holzknecht  treated  several  cases  of  cutaneous  affections  with  the 
radium  rays,  of  one  application  each.  One  was  a  case  of  psoriasis  gyrata 
of  the  entire  body,  which  had  been  nearly  cured  with  the  X-rays  and 
the  cure  was  completed  by  the  application  of  the  radium.  Very  slight 
and  brief  applications  of  the  X-rays  are  enough  to  cure  psoriasis.  The 
patches  heal,  while  the  sound  skin  is  not  affected  by  the  applications. 
The  same  is  true  of  the  radium. 

Francis  H.  Williams1  has  employed  radium  in  forty-two  cases,  and 
states  that  of  the  patients  treated,  9  were  suffering  from  acne,  2  each 
from  eczema  and  psoriasis,  and  4  from  lupus  vulgaris.  Of  the  33  re- 
maining, 1  was  keloid,  5  were  cases  of  rodent  ulcer,  23  of  epidermoid  car- 
cinoma, and  4  were  cancer  of  the  breast.  The  keloid  case  has  improved, 
2  of  the  5  cases  of  rodent  ulcer  have  healed,  and  three  show  improve- 
ment. Of  the  cases  of  epidermoid  cancer,  11  have  healed  and  12  are 
improving.  The  author  made  experiments  to  test  which  were  the  more 
beneficial,  the  beta  or  the  gamma  rays  from  radium ;  these  showed  that 
the  lift  a  rays  do  not  penetrate,  and  are  therefore  suited  for  superficial  treat- 
ment, while  the  gamma  rays  have  a  marked  power  of  penetration.  His 
conclusions  are  as  follows:  That  there  is  much  similarity  between  the 
action  of  the  radiations  from  radium  and  the  Rontgen  rays  ;  that  if  the 
results  obtained  by  radium  prove  permanent,  this  new  therapeutic  agent 
may  be  largely  used  instead  of  the  Rontgen  rays  ;  also  that  certain  diseases 
promise  to  yield  more  readily  to  treatment  by  radium  and  others  to  the 
Rontgen  rays.  He  argues  that  a  disease  that  has  attacked  different  parts 
of  the  body  of  a  given  patient  may  be  better  treated  in  certain  regions 
by  radium,  and  in  others  by  the  Rontgen  rays.  And,  lastly,  that  it  is 
quite  possible  that,  in  some  cases,  the  two  remedies  used  together  on  the 
same  area  and  at  the  same  sitting  may  accomplish  better  results  than  either 
employed  alone. 

Lassar 2  gives  illustrations  of  a  number  of  patients  with  melanoma  or 
cancroid  cured  by  application  of  1  mg.  of  radium  bromide,  in  a  small  cap- 
sule of  lead  foil,  upon  a  sheet  of  mica.  He  thinks  that  his  experience 
justifies  him  in  proclaiming  that  neoplasms  can  be  cured  with  radium 
in  the  hands  of  any  physician. 

M.  Danlos3  reports  a  case  of  lupus  of  the  face  exposed  to  the  action 
of  a  salt  of  radium,  at  two  points,  which  had  a  radio-activity  of  19,000 
from  24  to  36  hours.  The  result  was  disappearance  of  the  disease,  with 
the  formation  of  a  smooth,  white  cicatrix,  blending  into  the  surrounding 
normal  tissue. 

MM.  Hallopeau  and  Gadaud 4  report  that  too  prolonged  exposure 
to  the  emanations  from  radium  led  to  ulcerations  which  lasted  from  five 
to  six  months.  Dr.  Blandamour  has  also  used  radium  in  lupus.  His 

1  Medical  News,  Feb.  6,  190i.  'Derinat.  Zeit,  Berlin,  p.  1599. 

3  Revue  d'  Electrotherapie  et  Radioth^rapie,  Nov.  and  Dec.,  1902.  4Ibid. 


506  ELECTRO-THERAPEUTICS. 

best  results  followed  the  use  of  salts  with  a  radio-activity  of  5200  and 
19,000  respectively. 

The  exposures  were  made  for  from  twenty- four  to  forty  hours,  and 
were  followed  by  marked  erythema  with  maceration  of  the  tissues  ex- 
posed, and  even  ulceration.  The  recovery  was  perfect  and  the  cosmetic 
effect  good,  the  resulting  scar  being  white,  smooth,  and  soft.  By  modify- 
ing the  power  of  the  radium  and  shortening  the  exposure,  he  expressed 
the  hope  that  the  desired  effect  might  be  obtained  without  ulceration. 

Two  cases  reported  to  the  Viennese  Society  of  the  Imperial  Academy 
of  Science '  had  been  submitted  to  the  action  of  radium.  One,  a  man  aged 
62,  had  been  repeatedly  operated  on  for  cancer  of  the  palate  and  lip,  but 
with  no  benefit.  Further  operative  measures  had  been  declared  useless. 
In  the  published  report,  the  radio-activity  and  technic  were  not  given, 
but  a  bromide  of  radium  was  used.  The  tumors  gradually  and  com- 
pletely disappeared.  The  patient  was  treated  in  the  clinic  of  the  late 
Prof.  Gusenbauer.  The  second  case  was  one  of  melano-sarcoma  which 
was  also  reported  cured. 

Win.  Allen  Pusey  *  believes  that  the  effects  and  the  therapeutic  uses 
of  radium  are  in  some  respects  inferior  but  quite  analogous  to  the  action 
of  the  X-rays,  and  that  radium  finds  a  promising  field  in  the  treatment 
of  lupus  and  cutaneous  cancers. 

Einhorn 3  makes  some  observations  on  the  method  of  radium  treat- 
ment, its  physiology  and  diagnostic  value,  and  on  the  therapeutic  results 
he  has  obtained  in  the  treatment  of  carcinoma  of  the  oasophagus.  Kine 
cases  of  oesophageal  cancer  were  treated,  of  which  six  showed  some 
improvement.  Three  cases  were  not  improved.  None  of  these  latter 
received  adequate  treatment.  Pain  was  diminished  in  some  of  them. 
Dr.  John  B.  Shober  has  devised  the  radiode,  for  radium  applications  to 
the  less  accessible  cavities.  (Fig.  240.) 

Dr.  Mackenzie  Davidson,  *  of  Charing  Cross  Hospital,  London,  re- 
ports a  case  of  cancer  of  the  nose  cured  by  the  same  means.  Four  ex- 
posures, aggregating  an  hour  altogether,  were  given  at  intervals  of  a  few 
days.  In  three  weeks  healing  was  progressing  satisfactorily,  and  in  six 
weeks  the  growth  was  all  gone. 

Foveau  de  Courmelles5  describes  numerous  experiences  to  show  the 
great  sedative  power  possessed  by  radium.  It  soothes  pain,  whether  or- 
ganic or  cancerous,  nervous  or  neuralgic.  Some  cases  of  facial  neuralgia 
and  one  of  sciatica,  long  rebellious  to  other  measures,  yielded  to  the 
action  of  the  radium  rays.  The  girdle  pains  in  two  cases  of  ataxia  were 

1  New  York  Medical  Journal,  August  15,  1903. 

1  Journal  of  the  American  Medical  Association,  July  16,  1904. 

'New  York  Medical  Record,  July  30,  1904. 

4  Journal  of  tin-  Anu-rirun  Medical  Association,  June  25,  1904. 

6  Progres  Medical,  May  28,  1904. 


RADIUM  AXD  OTHER  SUBSTANCES.  507 

cured,  one  by  the  radium  and  the  other  by  the  Rontgen  rays.  The  subjects 
were  not  informed  in  regard  to  the  nature  of  the  treatment,  so  he  thinks 
that  suggestion  may  be  excluded. 

Eobert  Abbe '  employs  only  large  quantities  of  stronger  radium. 

15  centigrammes  Curie  radium,  strength 300,000 

l'l  milligrammes  (  u-rman  bromide,  strength    ....    1,000,000 

100  milligrammes  German  bromide,  strength 1,800,000 

The  working  unit  of  the  most  powerful  and  pure  radium  manufact- 
ured is  10  milligrammes  radium  bromide  1,800,000,  and  is  best  used  in  a 
small  cell  covered  by  a  thin  layer  of  mica. 

He  puts  35  of  his  cases  in  the  lupus  type,  including  the  epithelio- 
niata,  and  asserts  that  not  one  failed  to  show  a  marked  improvement. 

Twenty  have  been  cured,  at  least  for  the  time,  and  with  the  proba- 
bility that  many  are  permanent,  but  with  a  slight  point  or  two  of  recur- 
rence in  some,  which  always  have  yielded  to  a  short  secondary  treatment. 
Many  of  these  were  distinctly  malignant  epitheliomas. 

His  results  have  been  so  uniformly  excellent  in  the  treatment  of  the 
sarcomata,  that  he  unhesitatingly  advocates  radium  therapy  in  these 
cases  with  the  utmost  confidence. 

Exophthalmic  Goitre. — Robert  Abbe 2  reports  a  case  of  goitre  undesir- 
able for  operation.  An  opening  was  made  in  the  tumor,  into  wrhich  a  tube 
containing  radium  was  inserted  and  retained  there  for  twenty-four  hours. 
At  the  end  of  four  months  there  was  still  a  certain  degree  of  tachycardia, 
but  the  tumor  had  contracted  to  one-sixth  of  its  former  size.  Two  possible 
explanations  of  the  favorable  action  are  given  ;  there  may  be  retrograde 
changes  in  all  overgrown  tissue,  or  there  may  be  irradiation  of  the 
ganglia  of  the  sympathetic,  even  of  the  thoracic  and  cardiac  ganglia. 

Rabies. — Tizzoni3  describes  two  series  of  experiments  which  have  at- 
tracted much  attention.  In  the  first,  the  virus  was  exposed  in  vitro  to 
the  action  of  the  radium  rays  ;  in  the  second,  animals  were  inoculated  in 
the  eye,  or  sciatic  nerve,  or  under  the  dura  mater  with  virus,  and  the 
part  was  then  exposed  to  the  rays,  an  hour  a  day  for  eight  days.  The 
results  indicate  that  the  radium  rays  destroy  the  virus  of  rabies  both  in 
vitro  and  in  the  living  animal. 

Xa'nis. — Hartigan4  reports  a  case  of  nsevus  successfully  treated  by 
radium  bromide.  The  first  was  a  large  port-wine  nsevus  affecting  the 
whole  of  one  cheek  in  a  woman  of  twenty-six  years.  The  treatment 
lasted  nine  months,  during  which  time  thirty-nine  exposures  were  given, 
varying  from  half  an  hour  to  an  hour.  The  nsevus  entirely  disappeared, 

1  Journal  of  the  American  Medical  Association,  July  21,  1906. 
*  Archives  of  the  Rontgen  Ray,  March,  1905. 

3  Riforma  Medica,  Palermo  and  Naples,  last  indexed  vol.  xliv.  p.  1818. 

4  British  Journal  of  Dermatol.,  December,  1904  ;  Treatment,  April,  1905. 


'•US 


ELECTRO-THERAPEUTICS. 


witli  rhe  exception  of  a  few  untreated  areas.  The  amount  of  radium  used 
was  10  milligrammes.  Usually  within  twenty-four  hours  an  erythema  oc- 
curred, followed  by  vesicles,  which  fell  off  as  scabs  in  a  few  days,  leaving 
behind  a  thin  white  skin. 

Radio- Active  Treatment  with  Thorium. — Tracy1  illustrates  the  radio- 
activity of  thorium  and  calls  attention  to  its  anti-fermentative  property. 
He  suggests  two  methods  of  using  radio-activity  in  tuberculosis.  One  is 
by  using  a  saturated  solution  of  nitrate  of  thorium  in  a  large  shallow  re- 
ceptacle. A  slight  current  of  air  can  be  caused  to  pass  over  the  solution 
from  a  compressed  air  tank,  while  the  patient  is  inhaling.  With  the 
nitrate  of  thorium  there  may  be  more  or  less  free  nitric  acid  ;  this  must 

be  neutralized  by  passing  the  emana- 
tions, before  inhalation,  through  a  wash- 
bottle  containing  a  saturated  solution  of 
sodium  bicarbonate.  The  more  satisfac- 
tory way,  he  thinks,  is  by  heating  the 
oxide  of  thorium  by  the  Lieber  appa- 
ratus. The  procedure  leaves  in  the 
lungs  a  fine  film  of  radio-active  matter, 
which  in  turn  produces  the  phenomenon 
of  induced  radio-activity  in  the  same 
parts,  which  may  last  for  one  or  two  days. 
This  is  shown  by  the  patient,  after  inhal- 
ing thorium  emanations,  exhaling  on  a 
photographic  plate  which  produces  the 
ordinary  effects  on  the  silver  salts.  An 
inhalation  given  every  day  or  every 
other  day,  he  says,  will  keep  the  lung 
cells  constantly  in  a  radio-active  and 
antiseptic  condition.  The  heat  emanat- 
ing from  a  Lieber  apparatus  can  be 
cooled  by  passing  through  a  glass  and 

rubber  tubing,  and  the  inhalation  may  be  given  for  a  period  of  fifteen 
minutes  at  the  outset,  gradually  increasing  to  half  an  hour.  This 
method  of  treating  tuberculosis  will  not  interfere  with  medical,  dietetic, 
or  other  treatment. 

Sharp  *  reports  two  cases  of  pulmonary  tuberculosis  treated  by  inha- 
lations from  thorium  nitrate  solution.  In  both  cases  there  was  marked 
improvement,  the  patients  being  enabled  to  return  to  work.  The  appa- 
ratus employed  consisted  of  an  ordinary  gas  washing  bottle,  holding  500 
c.c.  of  water,  in  which  were  dissolved  100  grains  (6  grammes)  of  thorium 
nitrate.  When  dissolved,  any  excess  of  nitric  acid  was  neutralized  with 


FIG.  239.— UARTIGAS'S  RADIVM  AP- 
PLICATOR.—The  applicator  figured  here- 
with has  been  made  at  the  suggestion  of 
Mr.  Hartigan,  F.R.C.S..  Assist.  Surgeon, 
Blackfriars'  Hospital,  and  permits  of  the 
application  of  radium  to  hitherto  inacces- 
sible situations,  e.g.,  O3sophagus,  larynx, 
bladder,  etc.  It  is  practically  the  size  of  a 
No.  12  catheter  for  the  bladder,  suitable 
carriers  being  provided  for  internal  and 
extemal  application.  The  applicator  has 
a  Rpnerical  front  of  a  material  allowing  of 
the  utilization  of  the  maximum  efficiency 
of  the  radium. 


1  Medical  Record,  January  23,  1904. 
'New  York  Medical  Record,  June  4,  1903. 


RADIUM  AND  OTHER  SUBSTANCES.  509 

ammonia.  Two  patients  may  inhale  the  emanations  continuously  for  an 
hour  a  day  each  at  an  interval  of  eleven  hours,  it  taking  about  half  that 
long  for  the  gas  to  collect. 

Rheumatism. — Glanders,1  in  choosing  a  radio-active  substance  for  the 
relief  of  rheumatic  pain,  favors  thorium,  because ;  (1)  Its  radiations  are 
spontaneous  and  are  not  destroyed  by  a  physical  state  or  by  chemical 
transformation  ;  furthermore,  they  are  practically  inexhaustible  and  do 
not  need  stimulus  from  any  outside  source  of  energy ;  (2)  though  infi- 
nitely less  radio-active  than  radium,  thorium  is  much  more  active  than 
uranium  ;  it  is  rich  in  the  penetrating  beta  rays,  which  are  required  for 
deep  therapeusis,  and  poor  in  the  X-rays,  which  provoke  a  destructive 
molecular  change  in  the  elements  of  the  superficial  tissues. 

Hartigan,2  who  employs  his  radium  applicator  (Fig.  239),  treated  a 
woman  of  66,  with  a  scirrhus  of  the  breast  of  16  years'  duration.  She 
received  forty  applications  of  radium  bromide,  lasting  twenty  minutes 
each.  Twenty  milligrammes  of  radium  were  used.  The  pain  disap- 
peared, hemorrhage  ceased,  and  the  ulcer  began  to  heal.  Later  the 
growth  disappeared  and  the  ulcer  vanished. 

I  have  made  a  comparative  study  of  the  values  of  radium  and  the 
Rontgen  rays  on  a  series  of  epitheliomatous  cases.  Half  of  the  lesion 
was  covered  with  lead  when  exposing  to  the  X-rays,  and,  conversely,  when 
the  other  half  was  exposed  to  the  radium  emanations,  the  remaining  half 
of  the  face  was  shielded.  From  clinical  and  microscopic  observation  no 


FIG.  240.— SHOBER'S  RADIODE.— This  radiode  is  especially  designed  to  facilitate  the  application  of 
radium  for  medical  purposes,  especially  in  cases  where  applications  are  made  in  the  smaller  cavities  of 
the  body.  The  radium  Is  contained  in  an  aluminium  capsule  shown  on  the  tip  of  the  radiode  at  "  F". 
This  capsule  is  attached  to  a  slender  rod.  To  prevent  the  capsule  and  radiode  becoming  fouled  in  use, 
a  glass  protecting  tube  or  shield,  with  one  end  closed,  is  made  to  fit  snugly  over  the  radiode,  as 
shown  in  Fig.  "  G".  The  radiode  can  then  be  inserted  in  a  cavity  without  danger  of  contamination  in 
any  way.  Instead  of  the  glass  protecting  tube  as  shown  in  cut  "G",  we  can  supply  a  similiar  protecting 
tube  of  aluminium.  It  is  known  that  glass  has  the  effect  of  cutting  off  some  of  the  radium  rays,  and  for 
this  reason  some  operators  prefer  to  encase  the  radiode  in  an  aluminium  protecting  tube.  A  lead-lined 
box  is  supplied,  as  shown  at  "  H"  in  cut,  for  containing  the  capsule  of  radiode  when  not  in  use,  thus 
protecting  the  operator.  (Courtesy  of  Williams,  Brown,  &  Earle.) 

improvement  or  changes  were  evidenced  from  the  radium  therapy.  The 
results  from  the  use  of  the  X-rays  were  in  every  way  superior  and  gave 
good  practical  results.  Further  experiments  are  needed,  and  the  possi- 
bilities of  the  radium  are  promising.  In  this  country  Pififard,  William  J. 
Morton,  Dieffenbach,  RollinH.  Stevens,  and  many  others  report  favorable 
results  from  radium  therapy. 

1  Archives  of  the  Rontgen  Ray,  September,  1905. 

2  British  Journal  of  Dermatology,  December,  1904  ;  Treatment,  April,  1905. 


CHAPTER  VII 
PHOTOTHERAPY. 

IN  order  to  grasp  the  principles  involved  in  the  study  of  photo- 
therapy, it  is  necessary  to  understand  the  more  simple  elementary  facts 
concerning  the  physics  of  light  and  the  spectrum. 

Regarding  the  nature  of  light,  two  theories  have  been  advanced. 
Xewton  asserted  that  luminous  bodies  emitted  infinitely  small  particles 
in  parallel  lines,  which  produced  in  the  eye  the  sensation  of  light. 
Huyghens,  whose  view  now  generally  obtains,  formulated  the  theory  that 
light  is  produced  by  waves  or  undulations,  that  are  transmitted  with 
inconceivable  velocity  through  the  atmospheric  ether. 

All  light,  whether  natural,  as  that  from  the  sun  and  other  celestial 
bodies,  or  artificial, — i.e.,  the  electric  spark  or  ordinary  flames, — is  of  a 


INVISIBLE 


VISIBLE  RAYS 


INVISIBLE 


FIG.  241.— SOLAR  SPECTRUM.— Scheme  of  the  wave  lengths  of  different  radiations.  A  B  C  is  the 
curve  of  thermal  action  ;  D  E  F  G  is  the  curve  of  chemical  action  ;  H  I  K  is  the  curve  of  light  action, 
with  a  maximum  at  yellow. 

compound  nature.  If  a  ray  of  sunlight  be  suffered  to  fall  upon  a  glass 
prism,  it  is  diverted  from  its  original  direction,  and,  as  its  constituent 
colors  are  bent  unequally,  they  are  separated.  When  the  transmitted  light 
falls  upon  a  white  surface,  the  colors  become  visible,  the  tints  blending 
where  one  color  merges  into  another.  This  zone  of  blended  tints  is  called 
the  spectrum.  The  colors  seen  are  violet,  indigo,  blue,  green,  yellow, 
orange,  and  red. 

According  to  the  undulatory  theory  of  light,  each  of  these  constitu- 
ent colors  has  its  own  rate  of  vibration.     Red  has  the  lowest  and  vio- 
let the  highest  rate  of  vibration ;  the  former  is  least  refracted  or  retarded  ; 
the  latter  undergoes  most  refraction  or  retardation.  Different  colors  have 
510 


PHOTOTHERAPY.  511 

different  wave  lengths,  diminishing  from  red  to  violet,  so  that  those  color 
rays  in  relation  to  the  violet  end  of  the  spectrum  are  designated  ''rays 
of  lesser  wave  length,"  and  vice  iv/ *</. 

At  the  extremes  of  the  solar  spectrum  are  additional  rays.  Beyond 
the  red  rays  lie  the  infra-  or  ultra- red  rays  ;  beyond  the  violet  are  found 
the  ultra-violet  rays. 

The  luminous  rays  of  the  sun  are  accompanied  by  others,  possessing 
heating  powers,  the  temperature  increasing  from  violet  to  red.  In  the 
spectrum  obtained  by  passing  sunlight  through  prisms  of  rock  salt,  the 
highest  temperature  is  manifested  at  a  position  far  beyond  the  extremest 
visible  red  rays.  From  these  facts,  it  is  inferred  that  the  great  thermal 
rays  of  the  solar  system  are  at  the  same  time  the  least  refrangible. 

Directly  opposed  to  the  heat-rays  are  the  so-called  chemical  or 
actinic  rays.  The  latter  rays  are  capable  of  effecting  both  chemical 
combinations  and  chemical  decompositions,  as  is  evidenced  in  the  black- 
ening and  decomposition  of  the  silver  salts  in  photography.  As  before 
intimated,  these  chemical  rays  lie  beyond  the  violet  end  of  the  spec- 
trum, and  are  the  rays  that  are  instrumental  in  effecting  dermatitic 
changes.  (Fig.  241.) 

THE  ACTION  OF  LIGHT  ox  PLANTS. 

Plants  cannot  exist  without  light.  Through  its  agency  they  extract 
CO2  and  by  means  of  chlorophyll  assimilate  it.  Light  is  not  necessary 
for  the  germination  of  plants  and  seems  to  exert  a  retarding  effect  upon 
growth.  This  would  seem  to  account  for  the  varying  rate  of  growth  at 
different  hours  of  the  day.  Indeed  it  has  been  shown  that  all  light  rays 
except  the  red  and  ultra-red  retard  the  growth  of  plants,  and  that  the 
effect  is  most  pronounced  in  the  rays  that  suffer  most  refraction  in  the 
spectrum. 

"  Heliotropism  "  is  the  faculty,  possessed  by  many  parts  of  plants, 
of  turning  toward  and  away  from  the  direction  of  greatest  light.  Stems 
and  leaf-stalks  are  positively  heliotropic  (growing  toward  the  source  of 
light,  in  the  direction  of  the  light  rays),  while  roots  and  rhizomes  are,  as 
a  rule,  negatively  heliotropic. 

ACTION  OF  LIGHT  ON  BACTERIA. 

That  diffused  and  also  direct  light  can  destroy  the  bacteria  of  putre- 
faction was  first  enunciated  by  Downes  and  Blunt  in  1877.  *  They  like- 
wise showed  that  the  effect  is  the  same  whether  the  bacteria  are  moistened 
or  dried,  that  the  presence  of  oxygen  is  requisite,  and  that  the  manner 
in  which  light  a,cts  in  these  experiments  is  not  to  be  sought  in  a  modifica- 
tion of  the  nutritive  basis.  These  data  are  now  accepted  by  all  scientists. 

Proceedings  of  the  Royal  Society  of  London,  December  6,  1877,  vol.  xxvi.  p.  488, 
and  December  19, 1878,  vol.  xxviii.  p.  199. 


512  ELECTRO-THERAPEUTICS. 

Dieudonne  observed,  in  a  series  of  most  elaborate  experiments,  that 
bacteria  were  killed  in  thirty  minutes  by  direct  sunlight,  in  six  hours 
by  diffused  daylight,  in  eight  hours  by  the  Brush  light  of  900  candle- 
power,  and  in  eleven  hours  by  the  electric  incandescent  lamp.  It  is 
worthy  of  remark  that  very  many  observers  have  conclusively  demon- 
strated that  not  only  is  the  nutritive  basis  of  bacteria  unfavorably 
affected  by  light,  but  the  protoplasm  itself  suffers  a  direct  injury ;  it  is 
in  this  way  that  street  dust  is  in  a  great  degree  disinfected  by  its 
exposure  to  the  direct  rays  of  the  sun. 

THE  EFFECT  OF  LIGHT  ON  ANIMALS  AND  MAN. 

It  is  a  recognized  fact  that  many  animals  can  develop  only  in  the 
presence  of  light,  and  that  its  absence  causes  either  a  delay  or  a  complete 
suspension  of  development.  But  not  only  is  the  general  growth  affected 
by  varying  the  supply  of  light,  but  also  the  development  of  individual 
organs  and  parts  of  organs.  At  Finsen's  clinics  patients  and  nurses 
acquired  a  thicker  growth  of  hair  on  those  parts  constantly  exposed  to 
the  powerful  electric  rays. 

The  stimulus  given  to  change  of  form  and  the  transformation  of 
energy  through  the  agency  of  light  is  indeed  remarkable.  It  is  weD 
known  that  the  change  of  light  causes  change  of  form  in  the  cutaneous 
contracting  pigment-cells  of  many  amphibians,  reptiles,  and  fishes. 

That  ciliary  movement  is  regulated  or  modified  by  varying  the  color 
of  the  light  employed,  is  asserted  by  Uskoflf,  who  observed  that  the  epi- 
thelium of  the  cesophagus  is  equally  swift  in  red  and  violet  light,  but  is 
suspended  if  red  light  is  substituted  for  previously  acting  violet.  De 
Parville  claims  to  have  proved  that  the  red  end  of  the  spectrum  is  nerve 
irritating,  and  the  opposite  end  nerve  soothing.  On  the  higher  animals, 
light  produces  marked  effects  on  the  cuticle.  Those  parts  constantly 
exposed  to  the  light  become  coarser  and  harder,  the  protoplasm  becoming 
reduced  to  keratiue.  Indeed  Moeller l  demonstrated  that  light  produces 
a  hyperplasia  and  a  horning  process  of  the  skin.  Finsen  and  Moeller 
proved  by  experiment  that  skin  which  has  been  exposed  to  powerful 
chemical  rays  (blue,  ultra-violet)  retains  for  a  long  time  (months  and 
years)  a  peculiar  tendency  to  react  quickly  (by  reddening)  to  mechanical, 
thermal,  and  chemical  stimuli. 

We  know  that  pigment  is  a  protective  to  the  skin  against  the  action 
of  the  light  rays.  Freund2  mentions  the  case  of  a  dark-complexioned 
man  whose  body  and  face  showed  the  presence  of  many  vitiligo  patches, 
who,  after  a  long  walk  over  the  Grossglockner  glacier,  developed  a  vio- 
lent erythema  in  the  neighborhood  of  the  white  patches  on  the  face, 
but  in  these  regions  alone.  The  remainder  of  the  skin  was  unaffected. 

'Der  Einfluss  des  Lichtes  auf  die  Haut.  Biblioth.  med.,  Stuttgart,  1900,  p.  18. 
'"Elements  of  General  Radiotherapy,"  p.  420. 


PHOTOTHERAPY.  513 

Finsen  proved  that  acquired  pigmentation  may  also  have  protective  power 
against  the  injurious  action  of  light  rays.  He  painted  with  black  pig- 
ment a  ring  around  his  arm.  He  next  exposed  the  part  to  strong  sun- 
light for  three  hours.  After  a  time  the  skin  appeared  normal  save  at 
the  edge  of  the  painted  belt,  where  some  slight  erythema  was  noted.  A 
few  hours  subsequently  a  violent  erythematous  eruption  developed  in  the 
exposed  part,  but  the  painted  zone  appeared  unaltered.  Again  Finsen 
exposed  the  unpainted  part  to  the  sunlight ;  the  result  was  the  reverse, 
— /.  e.j  the  white  zone  was  destined  to  suffer  an  erythematous  change, 
the  remaining  parts  undergoing  no  alteration.  Many  observers  have 
since  shown  that  mild  erythema  and  light  pigmentations  are  due  to  the 
ultra-violet  rays. 

Blood  absorbs  light  in  a  high  degree,  this  being  especially  true  of 
haemoglobin.  Oxyhsemoglobin  gives  a  different  absorption  spectrum  from 
methiemoglobin.  Quiucke 1  showed  that  haemoglobin  gives  off  its  oxygen 
more  quickly  in  the  light  than  in  the  dark  ;  hence  light  augments  the 
oxidizing  power  of  the  blood  and,  correspondingly,  the  processes  of 
oxidation  in  the  human  economy. 

Godnew2  found  that  persons  and  animals  to  whom  daylight  was 
accessible  excreted  more  urine,  urea,  and  chlorides  than  those  remaining 
in  the  dark. 

THERAPEUTIC  ACTION  OF  LIGHT  ;  ITS  USE  AMONG  THE  ANCIENTS. 

The  therapeutic  value  of  light  and  the  appreciation  of  its  virtues  are 
almost  as  old  as  civilization  itself.  Historical  records  show  that  light 
was  valued  as  a  remedial  agent  centuries  ago  in  China,  Mexico,  Japan, 
the  West  India  Islands,  etc.,  the  patients  being  subjected  to  sun-baths  for 
therapeutic  purposes,  and  others  placed  in  total  darkness  as  a  means  of 
punishment 

The  ancient  Greeks,  who  lived  in  flat-roofed  houses,  were  accustomed 
to  expose  their  entire  bodies,  after  anointing  them,  to  the  sun,  believing 
that  its  powerful  rays  acted  very  beneficently  in  bringing  about  and  main- 
taining both  health  and  beauty  of  the  body.  In  the  essays  of  Cicero  and 
Yestricius  we  learn  that  the  Romans  were  accustomed  to  sun-baths,  these 
being  frequently  followed  by  cold  sponges.  Solaria,  or  out-buildings  de- 
voted to  these  baths,  were  quite  common  before  the  fall  of  the  Roman 
Empire.  Herodotus  recommended  sun-baths  for  those  who  were  feeble 
and  in  debilitated  health,  and  Antyllus  also  gave  elaborate  descriptions 
of  the  effects  of  the  sun's  rays  upon  the  human  body.  Not  only  was  the 
skin  treated  by  "  heliosis,"  but  also  such  diseases  as  jaundice,  nephritis, 
sciatica,  rheumatism,  nervous  and  mental  diseases.  During  the  Middle 
Ages  this  form  of  treatment  was  consigned  to  the  limbo  of  oblivion.  It 

1  Pfliiger's  Archiv,  1894,  vol.  Ivii.  p.  134. 

2  Zur.  Lehre  v.  d.  Einfluss  d.  Sonnenlichtes  auf  die  Thiere.  Kasanche  Dissert.,  1882. 


514  ELECTRO-THERAPEUTICS. 

was  during  the  19th  century  that  the  parasiticidal  action  of  light  engrossed 
the  attention  of  bacteriologists,  and  it  is  due  to  their  labors  that  the 
hidden  secrets  of  light  have  been  seized  by  eager  experimentalists  in  the 
hope  of  discovering  a  reliable  therapeutic  agent. 

TREATMENT  WITH  SUNLIGHT. 

Sunlight  is  the  most  natural  source  of  light,  but  its  use  depends  on 
the  weather,  and  upon  other  circumstances  which  affect  the  chemical 
intensity  as  well  as  the  optical  brightness.  Long  ago  it  was  indisputably 
shown  that  the  chemical  intensity  of  light  does  not  coincide  with  optical 
brightness.  The  chemical  light-intensity  of  the  sun's  rays  varies  with 
the  sun's  height  in  the  heavens.  In  the  summer  the  chemical  action  of 
the  sun  and  the  blue  light  of  the  sky  is  far  greater  than  during  the  winter 
season.  The  extent  to  which  the  air  absorbs  light  varies  with  the  amount 
of  vapor,  carbonic  acid,  and  suspended  dust  in  the  atmosphere. 

The  chemical  intensity  of  sunshine  increases  proportionately  with  a 
decrease  in  the  atmospheric  pressure.  Thus,  Timony  found  that  the 
ultra-violet  end  of  the  solar  spectrum  extended  much  further  toward  the 
more  strongly  refrangible  end  at  a  height  of  3500  meters  than  on  the  level 
of  a  table-land. 

Ordinary  sunlight  is  used  as  a  remedial  agent  in  the  form  of  baths. 
The  following  is  the  modus  operandi :  Place  the  patient  on  a  rug,  ele- 
vate the  head,  and  protect  him  from  the  wind,  in  a  veranda  entirely  open 
to  the  south.  Shield  the  eyes  with  dark  glasses.  The  bath  is  best  taken 
during  the  warm  season.  The  first  bath  occupies  a  duration  of  fifteen 
minutes,  which  may  be  subsequently  lengthened.  During  the  bath  the 
position  is  changed  at  intervals  so  that  different  parts  of  the  body  may 
be  exposed  to  the  light.  Maintain  these  positions  until  violent  perspira- 
tion occurs  on  these  parts.  This  is  to  be  followed  by  the  usual  water 
bath  (70°  to  80°  F.).  Have  the  patient  massaged,  and  advise  him  to 
exercise  thereafter. 

/ 
TREATMENT  WITH  THE  INCANDESCENT  LIGHT. 

The  incandescent  electric  light  is  poor  in  violet  and  blue  rays,  and 
rich  in  yellow,  red.  and  green.  Its  chemical  action  is,  therefore,  slight, 
but  this,  as  well  as  its  brightness,  may  be  materially  increased  by 
strengthening  the  current.  By  this  augmentation  we  not  only  affect  the 
optical  brightness,  but  also  its  blue  and  violet  rays.  Of  normal  power, 
380  incandescent  lamps  have  the  same  chemical  effect  as  natural  light  at 
a  distance  of  one  metre.  This  form  of  treatment  is  of  paramount  value 
where  the  longer- wave  rays  are  to  be  applied. 

The  modern  incandescent  baths  are  made  for  connection  with  the 
street  electric  wires.  They  consist  of  octagonal  boxes  supplied  with  panes 
of  mirrors,  with  a  movable  lid  above,  for  the  patient's  neck.  (Fig.  242.) 


FIG.  2-12.— Cabinet  for  the  treatment  of  diseases  by  the  employment  of  incandescent  lights. 

(Kny-Scheerer  Co. ) 


FIG.  24:i.— The  Flnsen  method  of  treatment. 


PHOTOTHERAPY.  515 

Forty  to  sixty  lamps,  of  16  candle-power  each,  line  the  inner  walls,  and 
are  so  arranged  that  they  can  be  put  in,  or  withdrawn  from  within  or 
without,  by  means  of  several  switches  in  series,  along  vertical,  horizontal, 
or  spiral  lines.  The  lamps  are  protected  by  a  lattice  work.  A  thermom- 
eter for  measuring  the  inside  temperature  is  fixed  on  the  wall.  A  win- 
dow is  sometimes  made  in  the  wall  of  the  chamber,  through  which  the 
pulse  and  the  course  of  the  perspiration  may  be  observed. 

The  patient  is  divested  of  his  clothing  and  placed  on  a  stool  in  the 
cabinet.  All  external  light  is  excluded  by  a  towel  placed  around  the 
neck  opening.  An  ice-cap  is  applied  to  the  head.  Begin  the  bath  at  a 
temperature  of  110°  F.,  and,  if  the  patient  reacts,  gradually  raise  it  to 
155°  or  165°  F.  The  bath  should  be  of  a  half-hour's  duration.  Increase 
the  temperature  by  increasing  the  number  of  lamps,  and  also  the 
strength  of  the  current.  Observe  the  pulse  carefully,  and  after  the  light- 
bath  employ  the  ordinary  water  bath  or  douche.  The  incandescent  bath 
acts  beneficially  by  radiating  heat.  In  this  way  heat  can  be  made  to 
affect  the  deeper  structures,  and  is  more  advantageous  than  the  Turkish 
or  Russian  baths,  which  at  best  only  exert  an  influence  on  the  surface  of 
the  body.  The  most  striking  effect  of  this  treatment  is  its  action  on  the 
secretion  of  sweat,  probably  due  to  stimulation  of  the  peripheral  nerve 
endings,  or  by  an  elevation  of  the  patient's  temperature,  or  by  a  com- 
bination of  both  these  factors.  The  incandescent  electric  light  is  of 
great  value  in  muscular  rheumatism,  in  the  various  forms  of  anaemia, 
in  arterio-sclerosis,  in  valvular  heart  disease,  in  neurasthenia,  migraine, 
tuberculosis,  etc. 

TREATMENT  WITH  THE  CONCENTRATED  ARC  LIGHT. 

Actinotherapy,  or  the  treatment  of  disease  by  the  application  of 
light,  was  inaugurated  by  Finsen.  Triumphant  over  the  intense  resist- 
ance that  greeted  his  earlier  efforts,  the  world  to-day  rings  with  his 
praises. 

Sunlight  is  undoubtedly  the  best  source  of  light,  but,  as  it  is  not 
always  available,  it  is  necessary  to  have  recourse  to  artificial  illumina- 
tion, especially  to  electric  light.  It  is  better  to  use  the  voltaic  arc,  for 
the  light  given  by  incandescent  lamps  contains  too  few  chemical  rays. 

Finsen' s  method  (Fig.  243)  consists  in  concentrating  actinic  light, 
through  rock-crystal  lenses,  on  any  desired  part,  rendered  as  exsanguine 
as  possible  by  means  of  pressure,  because  the  presence  of  blood  acts  as  a 
barrier  to  the  passage  of  the  chemical  rays  to  the  tissues. 

When  the  voltaic  arc  is  used,  60  to  80  amperes  of  current  are 
employed.  The  apparatus  consists  of  the  light,  the  cooling  apparatus, 
and  the  light-concentrating  apparatus.  From  the  source  of  light  there 
radiate  four  telescopes,  for  the  four  patients.  The  active  rays  are  ob- 
structed to  a  very  slight  degree  by  the  lenses  of  rock  crystal.  The  space 


ELECTRO-THERAPEUTICS. 


between  the  lenses  is  filled  with  water  to  moderate  the  temperature,  and 
a  surrounding  water-jacket  still  further  accomplishes  this  purpose.  As 
the  rays  from  this  artificial  light  are  divergent,  the  lenses  are  so  arranged 
as  to  make  them  converge.  The  rays  are  brought  to  a  focus  by  a  water- 
cooled  lens,  held  by  the  assistant,  who  presses  the  latter  firmly  on  the  part 
to  be  treated. 

The  applications  are  of  about  one  hour's  duration,  and  repeated 
daily.  A  few  hours  after  treatment,  erythema  with  some  tenderness  is 
often  manifested,  but  there  is  no  actual  pain. 

The  reaction  varies  in  different  cases,  but  it  is  always  seen  in  lupus 
vulgaris,  perhaps  never  in  lupus  erythematosus.  Following  a  few 

applications,  most  remarkable  iinproveTiicnt 
frequently  results.  Twenty  or  twenty-five 
applications  should  always  be  given  ;  after 
which  the  skin  will  usually  present  a  soft, 
pliable,  scarless  condition,  save  where  destruc- 
tion of  tissue  is  marked  by  the  earlier  ravages 
of  the  disease. 

THE  DERMO  OR  IRON  ELECTRODE  LAMP.— 
(Fig.  244.) 

As  the  chemical  composition  of  the  mate- 
rial composing  the  electrode  defines  the  quan- 
tity of  the  ultra-violet  rays,  experimenters 
have  been  on  the  alert  to  turn  this  principle 
to  advantage.  Although  many  electricians 
battled  with  the  problem  only  to  find  disap- 
pointment the  price  of  endeavor,  it  remained 
for  Bang,  of  the  Finsen  Institute  of  Copen- 
hagen, to  successfully  construct  a  lamp  with 
metallic  electrodes  suitable  for  phototherapy. 
By  using  iron  electrodes,,  and  tempering  their 
heat  by  water-circulation,  a  lamp  is  produced 
that  yields  a  maximum  of  chemical  rays  with 
a  minimum  production  of  heat.  This  lamp 

is  only  adapted  for  the  treatment  of  superficial  skin  diseases,  as  the  rays 

are  not  penetrative  but  diffusible  in  character. 

THE  COOPER-HEWITT  MERCURY- VAPOR  LAMP. 

Worthy  of  mention  is  the  Cooper-Hewitt  lamp,1  described  by 
Maurice  Leblanc,  and  which  briefly  is  as  follows : 

The  lamp  in  its  simplest  form  consists  of  a  glass  tube  about  70  cm. 

*Le  Radium,  Paris,  June,  1905. 


FIG.  244.— The  dermo  or  iron 
electrode  lump. 


PHOTOTHERAPY.  517 

long  and  about  3  cm.  in  diameter.  One  end,  the  upper,  is  enlarged  into 
a  bulb,  and  contains  a  cup-shaped  iron  electrode  which  becomes  the  anode 
of  the  device.  A  small  amount  of  mercury  at  the  lower  end  is  the 
cathode.  In  series  with  the  lamp  and  connected  at  the  anode  end  are  a 
resistance  and  an  adjustable  self-reductor. 

The  well-known  greenish  color  of  the  light  given  by  mercury  vapor 
when  glowing  under  an  electric  discharge  is  spoken  of  by  Leblauc.  He 
also  mentions  some  experiments  of  de  Eecklinghausen  in  mixing  some 
other  gases,  such  as  argon  and  helium,  with  the  contents  of  the  tube. 
These  were  conducted  with  a  view  to  correcting  this  serious  defect,  but  as 
yet  have  not  been  successful. 

This  lack  of  red  is  not  entirely  without  advantage  in  some  situa- 
tions, however.  The  Hewitt  light  has  been  found  admirable  for  its  non- 
excitable  character,  and  it  is  also  excellent  for  photographic  purposes. 

As  glass  absorbs  ultra-violet  rays,  lamps  have  been  made  of  quartz 
for  special  use  in  phototherapy  in  the  treatment  of  lupus. 

Most  normal  lamps  take  from  3  to  5  amperes  of  current,  and  have  an 
efficiency  of  about  0.45  watt  per  candle-power.  Several  special  forms  of 
bulbs  have  been  devised. 

THE  FINSEN  OR  BED  LIGHT  TREATMENT  OF  SMALLPOX. 

To  Kiels  Finsen  (Fig.  245),  more  than  any  one  else,  the  civilized 
world  owes  a  debt  of  gratitude  for  his  untiring  industry  and  indefatigable 
research  in  bringing  the  subject  of  the  therapeutic  action  of  light  to  the 
notice  of  the  medical  profession,  and  for  having  established  his  teachings 
upon  a  rational  basis.  So  profound  an  impression  did  he  make  upon  the 
minds  of  scientists  that,  in  1896,  the  government  of  Denmark  founded  a 
public  institution  for  the  purpose  of  carrying  out  the  principles  of  photo- 
therapy, and  especially  for  the  treatment  of  lupus  and  other  cutaneous 
affections  through  the  agency  of  concentrated  chemical  light. 

From  1893  until  almost  the  very  day  of  his  death,  Fiusen  had  been 
busily  engrossed  in  the  study  and  action  of  light  treatment,  but  it  is  his 
labor  to  prevent  the  pitting  from  variola  by  excluding  all  but  the  red 
light  that  has  won  him  deserved  renown. 

From  his  experiments  at  Copenhagen,  he  was  able  to  prove  that  the 
blue,  indigo,  violet,  and  ultra-violet  rays  of  the  solar  spectrum  are  the 
ones,  and  the  only  ones,  that  produce  chemical  effects  upon  animal 
tissues. 

As  far  back  as  the  sixteenth  century,  it  was  empirically  recognized 
that  the  pitting  from  smallpox  could  be  obviated  by  shading  the  doors 
and  windows  of  the  room  with  curtains  of  red  material.  Indeed,  the  use 
of  this  color  fabric  was  first  suggested  by  John  of  Gadesden  in  the  four- 
teenth century,  of  whom  Gregory  remarked,  ""What  think  ye  of  a  man, 
a  prince,  of  royal  blood  of  England  (John,  the  sou  of  Edward  the 


518  ELECTRO-THERAPEUTICS. 

Second),  being  treated  for  smallpox  by  being  put  into  a  bed  surrounded 
with  red  hangings,  covered  with  red  blankets  and  a  red  counterpane, 
gargling  his  throat  with  the  wine  of  the  mulberry,  and  sucking  the  red 
juice  of  the  pomegranates?  Yet  this  be  the  boasted  prescription  of  John 
of  Gadesden,  who  took  credit  of  no  meanness  to  himself  for  bringing  his 
royal  patient  safely  through  the  disease." 

Jn  1867  Black  had  published  in  the  London  "Lancet"  an  essay  on 
the  peculiar  influence  of  light  in  smallpox,  asserting  that  the  complete 
exclusion  of  light,  in  spite  of  the  fact  that  the  patient  had  not  been  pre- 
viously vaccinated,  effectually  prevented  pitting  of  the  face.  In  1871 
Waters  published  in  the  same  journal  a  declaration  that  the  severity 
of  a  case  of  variola  was  markedly  modified  by  the  exclusion  of  ordinary 
daylight. 

In  the  same  year,  Barlow  stated  that  he  was  able  to  distinguish  a  pro- 
nounced contrast  in  the  two  sides  of  a  patient's  face,  one  half  of  which 
had  been  covered  with  colored  gelatin  to  exclude  all  actinic  rays,  while 
the  opposite  half  of  the  face  was  allowed  to  remain  exposed  to  the 
influence  of  these  rays. 

Finsen,  a  poor  and  obscure  medical  instructor  in  a  little  Danish 
town,  devoted  his  spare  moments  to  experiments  and  observations  upon 
light,  with  a  hope  of  preventing  the  ugly  disfigurement  of  smallpox. 
What  he  aimed  to  ascertain  was  the  physiological  effect  of  light  on 
animal  and  vegetable  tissues.  As  the  result  of  the  experiments  he  soon 
arrived  at  very  important  conclusions  so  far  as  the  influence  of  light  was 
concerned  in  the  eruptive  diseases,  and  notably  so  in  smallpox.  By 
simple  reasoning  he  reached  his  first  great  discovery.  He  observed, 
when  earthworms  were  placed  in  an  oblong  box  covered  half  with  red 
glass  and  half  with  blue  glass,  that  they  would  invariably  crawl  away 
from  the  blue  light,  seeking  shelter  under  the  red  light.  In  the  light  cast 
by  the  blue  glass  they  were  intensely  active,  restless,  and  ill  at  ease  ;  in 
the  red  light  they  lay  quiet,  apparently  perfectly  contented. 

With  a  chameleon  he  conducted  a  peculiar  experiment.  He  placed 
the  little  reptile  in  such  a  position  that  one  half  of  its  body  was  under 
the  light  cast  by  blue  glass  and  the  other  half  in  that  cast  by  red.  He 
noted  that  the  parts  of  the  animal's  body  covered  by  blue  light  turned 
almost  black,  while  the  half  covered  by  the  red  light  presented  an 
almost  white  color.  From  this  he  concluded  that  the  creature  had  in  its 
integument  movable  pigment-cells  which  acted  as  a  barrier  against  the 
blue  light. 

Whilst  in  the  midst  of  his  experiments  and  researches  Finsen  wan- 
dered one  day  into  a  medical  library  in  Copenhagen,  where  an  article  of 
Dr.  Piteoe,  published  in  1832,  attracted  his  attention.  In  this  pamphlet 
it  was  mentioned  that  during  an  epidemic  of  smallpox  among  soldiers, 
those  confined  in  dungeons  suffered  from  the  disease  less  severely,  and 
recoveries  occurred  without  any  attempt  at  suppuration  and  consequent 


FIG.  245.— THE  LATE  PROFESSOR  NIELS  R.  FINSEN.— (Born  in  Faroe  Island,  Iceland,  December  15, 
1860.  Studied  medicine  at  Copenhagen  University  and  received  his  doctor's  degree  in  1890.  Awarded 
the  Nobel  Prize  and  the  Cameron  Prize  for  studies  in  practical  therapeutics  from  the  University  oi 
Edinburgh.  Died  September  24, 1905.) 


PHOTOTHEKAPY.  519 

scarring.  Finsen  grasped  its  meaning.  "Red  light  contains  no  actinic 
rays,7'  lie  reasoned  ;  "  why  not  use  red  glass  in  the  windows?"  this  being 
physiologically  the  same  as  darkness.  Thus,  he  suggested,  the  windows 
of  the  wards  or  rooms  in  the  hospitals  inhabited  by  sufferers  from 
smallpox  should  have  the  white  panes  removed  and  replaced  by  dark- 
ruby  glass  panes.  Personally  he  had  never  seen  a  case  of  smallpox,  but 
he  based  his  reasoning  on  theoretical  grounds. 

In  1893,  the  first  trial  of  this  therapeutic  agent  was  made  at  Bergen, 
in  Norway,  b}'  Dr.  Liudholm,  chief  physician  of  the  military  service, 
and  by  Dr.  Svendsen.  Eight  cases,  four  of  them  being  of  a  severe  type 
in  children  who  had  never  been  vaccinated,  were  treated,  the  results  being 
a  triumph  for  Dr.  Finsen.  Dr.  Svendsen  remarked,  "The  period  of  sup- 
puration, the  most  dangerous  and  most  painful  stage  of  the  disease,  did 
not  appear ;  there  was  no  elevation  of  temperature  and  no  osdema.  The 
patients  entered  the  stage  of  convalescence  immediately  after  the  stage  of 
vaccination,  which  seemed  a  little  prolonged.  The  hideous  scars  were 
avoided." 

Control  tests  showed  that  smallpox  cases  exposed  to  daylight  after 
beginning  the  red-light  treatment  invariably  suffered  suppuration  and 
scarring,  only  a  trifle  of  daylight  sufficing  to  do  harm,  the  irritated 
integument  being  almost  as  sensitive  to  the  actinic  rays  as  a  photo- 
graphic plate.  A  clear  red  light  of  such  intensity  as  to  permit  the 
patient  to  read  in  the  room  is  sufficient  in  ordinary  cases.  If  the  case  be 
a  very  severe  one,  it  is  necessary  to  employ  a  red  light  of  deeper  or 
darker  appearance. 

The  treatment  of  smallpox  by  the  exclusion  of  the  chemical  rays  of 
the  sun  has  now  been  tried  by  a  number  of  physicians,  chiefly  in  Den- 
mark, Sweden,  and  Norway.  Practically  all  of  these  men  have  been 
favorably  impressed  with  the  results. 

Mygind  (Denmark)  treated  22  cases  (variola  12,  varioloid  10)  ;  one 
died,  the  remainder  upon  leaving  the  hospital  had  hypenemic  spots  only. 

Abel  (Bergen,  Xorway)  had  23  cases,  8  of  them  very  severe.  One 
case,  admitted  very  late,  terminated  in  recovery,  but  with  suppuration. 
In  the  others  there  was  no  suppuration  and  no  scarring. 

Back  man  (Fever  Hospital  at  Koliikomaki)  treated  62  serious  cases, 
with  7  deaths  ;  the  remaining  55  recovered  without  scars. 

Feilberg  (Copenhagen)  used  the  method  in  11  cases.  There  was  no 
secondary  fever  and  no  pitting.  Pigmented  or  hypersemic  spots  were 
present. 

Strangard  (Denmark)  had  4  cases  ;  all  recovered  with  no  pitting. 

Benckert  (Gothenberg,  Sweden)  treated  16  cases  (5  were  varioloid 
and  11  were  variola)  ;  3  died ;  one  of  the  deaths  was  due  to  suppura- 
tion. Benckert  remarks,  "Suppuration  is  usually  abolished,  scars  are 
extremely  rare,  and  the  duration  of  the  disease  is  shorter." 

Finsen,  in  summing  up  these  cases,  says  that  out  of  a  total  of  140  to 


520  BLECTEO-THERAPBUTICB. 

150  cases  of  smallpox,  in  one  case  only  (that  of  Dr.  Benckert)  was  the 
method  inefficacious. 

The  Conditions  for  Success  by  Finxcn'*  M'tltod. — Two  conditions  are 
absolutely  indispensable  to  obtain  good  results  : 

1.  The  patient  should  be  placed  under  treatment  sufficiently  early. 
"When    the  patient    comes  under    treatment  early  enough,"    Finsen 
asserted,  "before  the  fourth  or  fifth  day  of  the  disease,  suppuration  of 
the  vesicles,  even  in  un vaccinated  persons  and  in  cases  of  coulluent 
smallpox,  will  be  avoided.     Should  the  patient  come  under  treatment 
after  the  fifth  day  of  the  disease,  it  is  uncertain  whether  suppuration  can 
be  avoided.     Sometimes  this  is  the  case,  sometimes  not." 

2.  "The  chemical  rays  of  daylight  should  be  absolutely  shut  out. 
The  efficiency  of  the  method  is  so  certain  that,  in  case  suppuration  should 
occur  in  a  patient  who  has  been  placed  under  the  treatment  in  proper 
time,  the  first  thing  to  be  thought  of  is  that,  from  want  of  care  either  on 
the  part  of  the  patient  or  of  the  nurse,  daylight  may  have  penetrated. 
Therefore,   before  the  method  can   justly  be  declared  a  failure,   the 
thoroughness  with  which  it  is  carried  out  should  be  tested  by  exposing 
photographic  plates  or  sensitized  paper  as  a  means  of  control  in  different 
places  in  the  sick-room.     If  these  photographic  plates  show  the  influence 
of  the  white  light,  the  technic  of  the  treatment  has  been  imperfect.     A 
few  of  those  who  have  applied  the  method  have  at  the  same  time  treated 
the  patient  by  other  remedies  as  well.     Such  a  course  is  objectionable  for 
scientific  purposes,  as  it  is  then  impossible  to  decide  which  agency  is 
responsible  for  the  results.     In  order  to  give  the  experiments  decisive 
scientific  value,  they  should  be  carried  out  under  strict  control,  and  the 
patient  placed  under  the  treatment  in  proper  time." 

BLUE  LIGHT. 

Before  closing,  I  wish  to  allude  to  the  therapeutic  use  of  blue  and 
ultra-violet  light.  The  subject  is  evidently  still  in  its  infancy,  and  much 
may  be  expected  from  the  successes  that  are  said  to  have  followed  its 
employment.  Already  there  are  many  authorities  who  extol  the  efficacy 
of  the  concentrated  actinic  rays  in  the  treatment  of  chronic  ulcers, 
lupus,  and  other  destructive  cutaneous  lesions. 

Blue  Light  as  an  Anaesthetic. — Within  recent  years  it  has  been  found 
feasible  to  employ  the  visible  chemical  frequencies  of  the  spectrum,  by 
the  use  of  screens  of  blue  glass.  This  glass  acts  as  a  barrier  to  the  pas- 
sage of  the  frequencies  of  the  ultra-violet  portion  of  the  spectrum,  and 
shields  from  the  frequencies  beyond  the  blue  or  the  yellow,  the  green  and 
red  frequencies. 

Minin,  of  St.  Petersburg,1  believes  that  the  visible  chemical  frequen- 
cies of  the  spectrum  from  the  blue  to  the  ultra-violet,  by  acting  on  the 

1  Journal  of  Physical  Therapeutics,  January  15,  1902. 


PHOTOTHERAPY.  521 

vaso- motor  nerves,  are  sedative  and  analgesic  in  nature.  He  asserts  that 
the  most  beneficial  results  are  to  be  found  when  the  source  of  light 
is  at  a  considerable  distance  from  the  area  to  be  treated,  thus  refut- 
ing the  hypothesis  that  the  action  produced  is  dependent  upon  residual 
thermal  energy.  Minhvs  view  now  generally  obtains,  that  by  the  agency 
of  isolated  visible  frequencies,  constriction  of  the  vessels  and  pronounced 
anaesthesia  result ;  while  white  light  effects  directly  opposite  results. 

Mr.  II.  Hilliard,  anaesthetist  at  the  London  Hospital,  has  used  blue 
light  as  an  anaesthetic '  after  M.  Redard's  method.2  He  says :  "Following 
M.  Redard's  plan,  I  have  out  of  a  total  of  thirty-two  cases  had  twenty 
absolutely  successful  results,  eight  failures,  and  four  cases  in  which  the 
patients  stated  that  they  felt  pain,  and  yet  showed  no  sign  of  doing  so 
beyond  'screwing  up'  their  eyes  during  the  operation.  Most  of  the 
failures  can,  I  think,  be  explained  on  the  grounds  that  the  patients  were 
highly  nervous,  that  they  had  while  waiting  their  turn  been  told  by  others 
that  some  new  experiment  was  being  tried,  and  that  they  did  not  carry 
out  my  directions  and  keep  their  eyes  fixed  upon  the  light.  The 
remainder  may  be  explained,  perhaps,  by  the  fact  that  a  different  reflector 
\v;is  used,  whereby  the  rays  were  not  concentrated  upon  the  patient's 
eyes,  but  were  more  widely  diffused. 

"In  addition  to  the  evidence  advanced  by  M.  Redard  against  the 
view  that  the  influence  of  the  light  is  hypnotic,  I  do  not  believe  that  so 
large  a  percentage  of  ordinary  persons  are  so  easily  hypnotized,  and  I 
find  that  the  results  vary  with  the  technic.  I  do  not  agree  with  M. 
Redard  in  the  opinion  that  a  general  anaesthetic  effect  is  produced,  for  I 
have  found  that,  although  sensation  in  the  extremities  is  temporarily  im- 
paired, yet  there  is  no  real  analgesia,  this  apparently  only  existing  over 
the  area  of  distribution  of  the  cranial  nerves. 

"In  all  the  successful  cases  dilatation  of  the  pupils  was  observed, 
and  in  two  or  three,  the  eyes  became  fixed  and  the  lids  drooped,  the  pa- 
tient developing  a  somnolent  condition  ;  but  in  those  instances  in  which 
the  patient  moves  his  eyes  constantly  and  blinks,  the  pupils  will  not 
dilate,  and  no  analgesic  effect  should  be  expected.  " 

1  British  Medical  Journal,  July,  1905. 

2  Lancet,  May  12,  1905. 


APPENDIX 


TECHNIC   OF   RONTGEN   BAY   THERAPY 

DURING  the  preparation  of  the  present  volume,  I  conceived  the  idea  of  address- 
ing letters  to  some  of  the  better  known  Rontgen  therapists,  asking  that  they  supply 
the  data  of  their  technic  on  the  blank  enclosed  for  that  purpose. 

I  was  gratified  by  the  cordial  responses  that  my  communications  elicited,  and 
interested  in  the  widely  divergent  opinions,  that  have  their  adherents  in  this 
country  and  abroad. 

The  statements  offered,  in  several  instances,  were  so  comprehensive  that  space 
was  lacking  to  record  the  data.  In  those  cases,  an  asterisk  (*)  has  been  placed, 
referring  the  reader  to  a  detailed  explanation  in  the  addendum. 

The  following  abbreviations  have  been  employed,  which,  like  the  tabulation 
itself  and  the  addendum,  are  arranged  in  alphabetical  order. 


COILS. 

A-N . = Apps-Newton . 

C.=Caldwell. 
Fes.=Fessenden. 
K.  &  K.=Kelley  and  Koett. 
K.=Kinraide. 
L.= Leeds. 
L.  &  N.=Leeds  and  Northrup. 

Q.=Queen. 

R.,  G.  &  S.=Reiniger,  Gebbert  and  Schall. 
Ruhm.=Ruhmkorff. 

R.  \  __ Rontgen. 

R.  M'f'g.  Co.]  "Rontgen  Manufacturing  Co. 
Sch.=Scheidel. 
Sn.=Snook. 

W.  &  B.=Waite  and  Bartlett. 
Will.=Willyoung. 


INTERRUPTERS. 

D.=Davidson. 

G:ii.     Gaiffp. 

K.      Kinniidp. 

R.=R6ntgen. 
W.=Wehnelt. 


STATIC  MACHINES. 


V.  &  T.= 


Columb.=Columbia. 

fVan  Houten  and 
\     Ten  Broeck. 
Wag.=Wagner. 
W.  &  B.=Waite  and  Bartlett. 


VACUUM  TUBES. 

F.=Friedlander. 
G.  &  B.=Green  and  Bauer. 

G.=Gundelach. 

M.  &  W.=Macalaster  and  Wiggin. 
Mach.=Machlett. 
Mon.=Monell. 
M.=MUller. 
Q.=Queen. 
W.  &  B.=Waite  and  Bartlett. 


APPENDIX.  523 


ADDEXDOI   TO  THE   SYNOPSES  OX  TECHXIC  DsT   ROXTGEX 

KAY   THERAPY 

BAETJER,  F.  H.  He  uses  20  volts,  ten  amperes  on  two  small  coils  ;  110  volts 
direct  current.  He  employs  different  makes  of  coils  :  Heinze  20-inch,  Queen  9-inch, 
and  Biddle  9-  and  18-inch,  respectively.  He  uses  a  hammerless  interrupter  on  each 
9-inch  coil ;  the  Wehnelt  on  the  18-inch.  Vacuum  tubes  include :  Queen,  Heinze, 
Swett  and  Lewis,  Miiller,  etc.  He  employs  large  (110  v.)  and  small  (20  v.)  coils ;  and 
believes  that  an  erythema  is  necessary  in  all  cases,  except  those  of  very  superficial  skin 
lesions. 

BARNUM,  O.  SHEPARD.  Barnum  uses  his  own  penetrameter,  and  remarks  that 
his  average  length  of  treatment  is  entirely  too  variable  to  state.  He  protects  the 
healthy  part  by  placing  a  shield  around  the  tube  and  lead-foil  on  the  patient. 

BRENEMAN,  PARK  P.  Breneman  varies  the  frequencies  of  his  irradiations,  giving 
treatments  twice  or  thrice  weekly  and  then  again  only  three  times  every  two  weeks. 

CALDWELL,  E.  W.  Ten-inch  coil  of  his  own  design,  rotary  mechanical  break,  20 
breaks  per  second  ;  "  break  "  lasts  ^  second  and  the  "  make  "  fa.  Uses  the  alumin- 
ium screen  for  deep  parts.  For  lupus,  low  penetration  and  no  screen.  He  writes  : 
"  I  use  any  old  tube  that  is  not  good  enough  for  radiographic  work  or  that  needs 
seasoning  for  that  purpose."  He  declares  that  the  static  machine,  for  X-ray  work,  is 
useless. 

DUNHAM,  KENXON.  He  believes  that  a  French  tube  is  best ;  he  also  employs  the 
Friedlander  and  the  Gundelach.  He  has  not  found  self-regulating  tubes  valuable, 
unless  personally  regulated.  He  says  that  the  distance  of  the  anode  from  the  patient's 
skin  varies,  because  he  brings  the  glass  to  within  one  inch  of  the  cutaneous  surface. 
His  voltage  (primary)  is  40  to  90,  with  load  ;  115,  without  load ;  and  he  has  the  anode 
red  hot  (usually),  before  treatment  is  finished.  He  regards  the  spintermeter  and 
penetrameter  as  inaccurate,  so  that  he  prefers  a  new  method.  He  protects  the  parts 
very  carefully,  but  not  close  to  the  lesion.  An  erythema,  he  asserts,  is  necessary  in 
lupus,  mycosis  fungoides,  epithelioma,  etc.  He  often  gives  daily  treatment ;  at  other 
times  only  once  in  two  weeks. 

FRANKLIN,  MILTON  W.  He  estimates  the  degree  of  vacuum  of  the  tube  by  both 
the  spintermeter  and  the  penetrameter  ;  preferring  Holzknecht's  method  of  standard- 
ization of  the  electroscope  and  the  Franklin  electroscope  for  general  use.  It  is  his 
practice  to  cover  everything  with  lead  except  the  lesion.  The  best  indication  to 
cease  the  treatment  is  the  presence  of  any  inflammatory  sign  on  the  healthy  skin  ;  his 
only  other  rule  is,  when  excessive  sloughing  occurs  on  an  open  lesion. 

FREUND,  LEOPOLD.  For  superficial  lesions,  a  soft  tube  (Wehnelt-ekiameter), 
5-12  cm. ;  for  subcutaneous  and  deep-seated  lesions,  a  hard  tube  (Wehnelt-skiameter), 
10-15  cm.  In  treating  the  more  deeply  seated  affections,  Freund  is  guided  by  the 
green-blue  light  of  the  tube  ;  in  superficial  affections,  by  a  deep  yellow  fluorescence. 
He  emphasizes  the  question  of  individuality,  idiosyncrasy,  etc.,  and  advocates  repeated 
small  doses  until  slight  reaction — i.e..,  swelling,  redness,  pigmentation,  etc. — ensues. 
He  protects  the  patient  with  lead-foil  or  mercurial  plaster  and  urges  the  operator  to 
seek  his  own  protection  in  a  lead  apron,  spectacles,  etc.  He  believes  that  treatment 
should  temporarily  cease  when  inflammatory  signs,  with  pigmentation,  epilation,  and 
subjective  symptoms  are  evidenced.  He  formerly  condemned  the  employment  of 
Liquor  Burowii  as  being  an  irritant  in  acute  cases,1  but  recently  he  advocates  the 
treatment,  which  I  have  appended,  in  his  technic. 

GIBSON,  J.  D.  Gibson  brings  the  anode  close  to  the  affected  area  in  cutaneous 
lesions,  and  as  distant  as  18  inches  for  deep-seated  influence.  Amperage  for  deep 
penetration,  5  to  10,  superficial,  1  to  2.  For  pulmonary  cases,  he  employs  a  quantity 
of  rays  equivalent  to  that  required  to  take  a  skiagraph  in  from  30  to  60  seconds.  He 

1  Elements  of  General  Radiotherapy,  by  Leopold  Freund,  translated  by  G.  H.  Lancashire,  1904, 
p.  348. 


524  APPENDIX. 

measures  dosage  by  the  fluoroscope  and  spark-gap.  He  ceases  treatment  at  the 
appearance  of  an  erythema  or  an  elevation  of  temperature.  He  approves  of  the 
production  of  an  erythema  in  malignant  and  superficial  affections. 

GIRDWOOD,  G.  P.  Current  of  220  volts  from  the  street ;  in  the  hospital  110  v. 
For  hospital  use  a  12-inch  Biddle  coil  and  a  10-inch  Leslie  Miller.  In  the  office  a  6- 
inch  (Chadwick)  mercury  dip  and  a  12-inch  Apps  coil.  He  varies  his  interrupter 
according  to  his  coil  and  tube,  from  300  mechanical  to  3000  electrolytic.  He  em- 
ploys a  voltage  of  220  cut  down  by  the  rheostat  to  200.  He  is  guided  in  his  dosage 
by  a  greenish-yellow  fluorescence  of  the  tube. 

GRUBBE,  EMIL  H.  A  subdued  fluorescence  of  the  luminous  hemisphere  of  the 
tube  is  his  guide  ;  the  vacuum  is  estimated  by  the  resistance  of  the  tube,  as  compared 
with  air  resistance  between  the  prime  conductors  of  the  generator.  He  protects  the 
healthy  parts  by  means  of  Grubbe's  X-ray  foil.  He  believes  that  an  erythema  is 
necessary  in  the  treatment  of  all  superficial  lesions. 

HALL-EDWARDS,  J.  He  uses  German  and  French  makes  of  vacuum  tubes,  and 
finds  the  non-regulating  best  for  radiography,  the  self-regulating  for  treatment.  He 
uses  all  tubes,  no  matter  what  the  vacuum,  at  from  4  to  12  inches.  He  employs 
the  radiochromometer,  radiometer,  etc.,  for  experimentation  only.  He  protects  the 
healthy  parts  by  plaster  of  Paris  masks  and  a  bandage  covered  with  lead-foil. 
He  writes  me  that  in  all  his  varied  experience — Officer  in  Charge  of  the  X-ray 
Department  of  the  Birmingham  General  Hospital  and  late  of  the  Imperial  Yeomanry 
Hospitals  in  South  Africa — he  has  found  nothing  to  relieve  the  painful,  chronic 
dermatitis,  from  which  he  is  a  sufferer. 

HETHERINGTON,  J.  P.  He  uses  his  own  water-cooled  interrupter  or  the  Kin- 
raide,  the  number  of  interruptions  in  either  being  about  equal  to  the  Wehnelt.  He 
uses  a  variety  of  vacuum  tubes,  among  which  may  be  mentioned  :  The  Queen,  Volt- 
Ohm,  Friedlander,  Wagner,  Swett  and  Lewis,  Miiller,  etc.  He  tells  me  that  he  pre- 
fers the  non-regulating  and  the  self-regulating,  to  the  osmo-regulating,  variety.  For 
cutaneous  lesions,  he  brings  the  anode  as  close  as  possible  to  the  part,  unless  the 
affected  area  is  very  large  ;  in  deep-seated  conditions,  as  low  a  vacuum  as  will  pene- 
trate to  the  desired  depth.  He  only  uses  lead  to  protect  special  parts,  such  as  the 
hair  ;  and  discontinues  treatment  at  a  commencing  erythema,  or  disappearance  of  the 
lesion.  He  believes  an  erythema  is  necessary  to  obtain  rapid  results,  or  to  remove 
hair.  It  is  his  aim  to  produce  erythema  in  nearly  every  case. 

HOLDING,  A.  The  indication  to  discontinue  treatment  is  a  "slight  erythema." 
He  says  that  "  a  slight  erythema  may  at  times  be  necessary  in  superficial  skin  lesions, 
but  even  then  it  is  to  be  avoided  if  possible."  He  believes  that  prevention  is  better 
than  all  the  cures  for  X-ray  dermatitis. 

KIENBOCK,  ROBERT.  He  approves  of  the  Benoist-Walter  radiochromometer, 
average  penetration  4  to  6,  mostly  5.  He  uses  his  quantimeter  in  conjunction  with 
Sabouraud-Noir6  radiometer  for  dosage,  and  for  comparison  by  artificial  illumination 
he  takes  advantage  of  Scheiner's  benzine  lamp.  He  believes  that  a  complete  treat- 
ment by  massive  doses,  once  or  twice  monthly,  is  the  most  effective  method.  He  is 
much  opposed  to  frequently  repeated  irradiations. 

LAQUERRIERE,  ALBERT.  The  milliamperage  in  the  secondary  is  measured  by 
Gaiffe's  milliamperemeter,  the  length  of  the  spark  by  the  spintermeter.  The  pene- 
tration is  determined  by  the  radiochromometer  of  Benoist,  and  the  dosage  by  the 
radiometer  of  Sabouraud  and  Noire".  The  occurrence  of  erythema  causes  him  no 
fear,  indeed  he  often  looks  for  a  certain  determinate  degree  of  it ;  he  believes  that 
its  likelihood  can  never  be  rigorously  excluded,  as  idiosyncrasy  plays  so  largely  the 
role.  He  asserts  that  an  erythema  is  beneficial  in  certain  rebellious  cases  of  lupus 
and  in  some  of  the  epithehomata.  The  various  kinds  of  apparatus  devised  by  Gaiffe 
are  much  in  vogue  in  France. 

LEONARD,  CHAS.  L.  Leonard  uses,  as  protective  measures,  a  lead-covered  box, 
a  lead-glass  shield,  and  an  aluminium  screen.  He  believes  an  erythema  necessary  when 
the  disease  will  not  yield  without. 

MORTON,  REGINALD.  He  advises  the  employment  of  the  Apps-Newton  coil. 
He  finds  that  the  best  results  in  his  work  are  accomplished  by  two  ten-inch  coils  and 
one  eighteen- inch.  He  estimates  his  dosage  by  the  apple-rgreen  color  of  the  tube, 


APPENDIX.  525 

with  the  anode  dull-red.  At  the  appearance  of  slight  dermatitis  he  discontinues  treat- 
ment. Nevertheless,  he  believes  that  the  more  severe  the  lesion,  the  more  necessary 
it  i.s  to  bring  about  definite  but  not  severe  reaction.  Dr.  Morton  informs  me  that 
the  London  Hospital,  to  which  he  is  the  radiologist,  treats  the  superficial  cutaneous 
lesions,  including  rodent  ulcer,  in  the  department  of  dermatology  ;  cases  of  malignant 
and  constitutional  disease  are  cared  for  in  the  electrical  department  under  his  super- 
vision. 

MORTON*,  WM.  J.  His  guide  in  dosage  is  the  fluorescence  of  the  tube  only.  He 
doubts  if  an  erythema  is  ever  really  necessary  ;  asserting  that  in  three  weeks'  time 
a  mild  erythema  usually  develops,  followed  by  tanning.  He  employs  only  high- 
vacuum  tubes,  preferably  old  and  "  hardened  ";  these  giving  "a  'therapeutic'  X- 
ray,  in  contradistinction  to  the  quality  of  the  X-ray  best  adapted  to  making  a  good 
skiagraph."  He  believes  that  his  method  is  much  safer  as  regards  X-ray  burns. 

NEWCOMET,  WM.  S.  He  estimates  the  degree  of  vacuum  by  the  appearance  of 
the  tube  and  spark-gap.  He  believes  the  time  to  discontinue  treatment  is  when 
the  treatment  is  no  longer  needed,  and  that  an  erythema  is  not  necessary.  He 
remarks  that  the  occurrence  of  erythema  is  not  necessary — it  is  accidental. 

PANCOAST,  HENRY  K.  Pancoast  uses  the  mechanical  spring  interrupter  for 
therapeusis  ;  the  Wehnelt  interrupter  for  radiographic  work  ;  the  Queen  and  Gunde- 
lach  tubes  for  superficial  treatment  ;  the  Queen,  Macalaster  and  Wiggin  tubes  for  deeper 
work.  With  the  mechanical  spring  interrupter  and  a  24-inch  coil,  his  amperage  is  2 
to  3  ;  on  18-inch  coils  it  is  usually  more.  He  estimates  the  vacuum  of  tne  tube  by 
equivalent  spark  length  when  the  tube  is  known  to  be  reliable  and  constant ;  other- 
wise he  resorts  to  the  Benoist  scale  in  addition.  He  tells  me  that  his  average  length 
of  treatment  is  a  very  variable  quantity:  for  the  average  case  of  epithelioma,  10  to 
15  minutes  three  to  five  times  per  week.  He  protects  the  healthy  parts  by  the 
diaphragm  of  the  tube  shield,  lead-foil  or  wet  leather.  He  remarks  that  treatment 
should  be  discontinued  when  it  is  certain  that  the  condition  has  been  cured,  and  that  the 
production  of  an  erythema  is  a  poor  and  misleading  guide.  As  a  prophylactic  measure 
against  X-ray  dermatitis  alcohol  with  talcum  powder  or  stearate  of  zinc  is  recom- 
mended. The  above  will  also  answer  for  burns  of  the  first  degree,  or  an  evaporating 
lotion  of  lead  water  and  laudanum  may  be  used  for  a  slight  dermatitis.  For  burns  of 
the  second  degree  :  dry  powder  ;  lead  water  and  laudanum ;  zinc  oxide  ointment ; 
or  picric  acid  solution  1-1000.  For  burns  of  the  third  degree  :  zinc  ointment,  or 
picric  acid  solution.  For  pain:  lead  water  and  laudanum  or  orthoform.  For  burns 
of  the  fourth  degree  :  the  same  ;  to  be  treated  more  as  a  surgical  condition.  Chronic 
ulceration  of  the  patient,  Pancoast  regards  as  a  surgical  condition.  In  some  cases 
picric  acid  has  been  satisfactory.  If  healing  is  obstinate,  excise,  allow  the  ulcer  to 
heal,  or  skin  graft,  or  suture  the  edges  together. 

PFAHLER,  G.  E.  He  employs  a  7-inch  Leeds  coil  and  a  number  of  coils  of  the 
Rontgen  Manufacturing  Co. — 9-,  15-.  18-,  and  20-inch.  The  vacuum  tubes  that  he  pre- 
fers include':  Heinze  and  Bauer,  Green  and  Bauer,  Miiller,  Friedlander,  Machlett, 
Macalaster  and  Wiggin.  He  is  of  the  opinion  that  a  dermatitis  or  toxaemia  is  a  danger 
signal  for  the  operator,  and  that  it  is  seldom  necessary  to  produce  an  erythema 
except  when  irradiating  superficial  lesions. 

PRICE,  WESTON  A.  He  uses  a  large  number  of  coils,  interrupters,  and  tubes, 
but  fails  to  give  their  make  or  names.  The  distance  of  the  anode  from  the  patient's 
skin  varies  ;  usually  it  is  from  6  to  10  inches.  He  states  that  his  vacuum  tubes  also 
vary  very  much  in  superficial,  subcutaneous,  and  deep-seated  conditions.  "  For  my 
dental  work,"  he  writes,  "  I  use  very  high  amperage  and  very  high  penetration, 
modifying  these  with  different  conditions." 

RuDis-JicmsKY,  J.  With  the  static  machine,  200  to  300  revolutions  per 
minute  for  therapy,  500  for  skiagraphy.  Length  of  spark-gap,  18  inches  (maximum). 
In  therapy  he  also  employs  a  12-inch  coil  with  two  layers  of  primary  connection  in 
series  ;  interruptions,  10  per  second  ;  primary  current,  2£  amperes  ;  direct  current, 
110  volte.  For  superficial  lesions  he  is  guided  by  a  yellow-green  fluorescence  of 
the  tube  ;  for  deep  affections,  by  what  he  terms  "a  perfect  green."  He  varies  his 
len<tth  of  treatment  "  according  to  each  individual  case,  the  condition  of  the  patient, 
and  the  condition  of  the  tube."  He  informs  me  that  in  his  belief  all  "  deep  cases 
should  undergo  a  "  tanning,  "  and  that  the  production  of  an  erythema  is  only  justifi- 
able in  a  few  obstinate  diseases. 


526  APPENDIX. 

SCHAMBERG,  J.  F.  He  uses  Queen,  Muller  and  Gundelach  (regulating)  tubes. 
One-fifth  to  two-fifths  milliampere  with  medium  high  tubes  ;  three-fifths  to  one  and 
three-fifths  milliamperes  for  low  tubes.  For  accurate  dosage  Schamberg  depends  upon 
Benoist's  radiochromometer  ;  regarding  No.  3  as  fairly  exact  for  superficial  lesions, 
and  from  6  to  8  for  the  deeper  varieties.  The  average  length  of  treatment  in  cuta- 
neous affections  is  5  to  6  minutes  twice  or  thrice  weekly.  He  asserts  that  erythema, 
especially  if  it  occur  early  following  vigorous  treatment,  is  an  indication  that  the 
irradiations  should  be  discontinued.  It  is  his  belief  that  in  ordinary  cutaneous 
affections,  such  as  acne,  an  erythema  is  not  a  sine  qua  non,  but  that  its  production 
acts  as  a  remedial  measure. 

SCOTT,  J.  N.  Scott  says :  "I  try  to  use  the  same  tube  on  the  same  patient. 
Upon  beginning  treatment,  I  record  the  length  of  treatment,  amperage,  number  of 
interruptions,  spark-length  that  the  tube  will  'back  up,'  etc.  I  gradually  lengthen 
the  treatment  until  an  erythema  is  evidenced,  basing  future  treatments  on  the 
above  data."  He  irradiates  epithelioma  every  day,  and  deeper  growths  every  second 
or  third  day.  He  protects  the  patient  by  a  metallic  box  which  has  adjustable 
openings  for  the  passage  of  the  rays.  He  believes  that  an  erythema  is  necessary  in 
every  case,  except  when  the  eye  is  involved. 

SHOBER,  JOHN  B.  He  judges  of  the  dosage  by  a  whitish-yellow  to  a  light  green 
fluorescence  of  the  tube  ;  the  anode  normal  to  cherry-red.  He  estimates  the  degree 
of  vacuum  by  the  spark-gap  on  the  coil  and  tube,  the  amperage  in  the  primary 
current,  the  degree  of  the  fluorescence  in  the  fluoroscope,  etc.  He  discontinues  treat- 
ment if  the  case  is  getting  worse,  instead  of  better  ("  toxaemia  ").  He  says  :  "  Of  late 
I  prefer  to  use  Curie  300,000  radium  bromide,  20  milligrammes  in  two  aluminium 
capsules,  2  to  3  times  weekly,  from  1  to  3  or  4  hours  ;  valuable  in  furunculosis,  boils, 
carbuncles,  moles,  warts,  nsevi,  epithelioma,  sarcoma,  etc." 

SMITH,  J.  F.  Dosage  is  determined  by  a  light  to  dark  green  fluorescence  of  the 
tube  ;  "  the  heavy  anodes,"  he  asserts,  "do  not  get  red  hot."  He  believes  that  the 
best  time  to  discontinue  treatment  is  at  the  appearance  of  any  erythema,  taking  into 
consideration  the  duration  and  number  of  the  exposures. 

STEWART,  THOS.  J.  For  superficial  conditions  he  uses  a  Queen  tube  or  one  that 
can  be  kept  low.  In  his  work  he  employs  the  Gundelach,  Queen,  and  Muller  tubes  ; 
using  the  first  and  last  for  therapy.  He  believes  that  the  maximum  quantity  of 
rays  is  emanating  from  the  tube  when  the  anode  is  of  a  dull  red  color.  He  thinks 
it  necessary  to  produce  an  erythema  to  determine  the  maximum  individual  dose. 

STOVER,  G.  H.  Stover  uses  a  great  variety  of  coils,  interrupters,  and  tubes. 
Among  the  coils  may  be  mentioned  :  Heinze  12-inch,  Scheidel  12-inch,  Meyer  6-inch, 
etc.  The  vacuum  tubes  include  Green  and  Bauer,  Macalaster  and  Wiggin,  Swett  ami 
Lewis,  Muller,  etc.  In  estimating  the  vacuum  of  the  tube  he  takes  into  consideration 
the  primary  current,  the  appearance  of  the  tube,  and  the  spintermeter-gap.  He  gives 
ten  minutes'  treatment  to  cutaneous  diseases  and  from  10  to  15  minutes'  for  sub- 
cutaneous and  deeper  affections.  He  believes  that  the  best  time  to  discontinue  treat- 
ment is  at  the  approach  of  cure  or  transient  or  definite  erythema.  He  asserts  that  in 
lupus  vulgaris  and  cutaneous  epithelioma,  the  production  of  an  erythema  is  necessary. 

WALSH,  DAVID.  Walsh  writes  me  that  of  late  he  has  not  followed  up  the  thera- 
peutic aspect  of  the  X-rays,  beyond  treating  a  few  cases  of  ringworm,  recurrent 
carcinoma,  and  rodent  ulcer.  He  remarks  that  his  publications  contain  much  of  his 
technic. 


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Morton  Win  J    

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Rudis-Jiclnsky,  J  

Cedar  Rapids,  la.  . 
Philadelphia,  Pa.. 

V.&T  

10 

•.(•0-31M* 

32 

M 

18 

Schamberg,  J.  F  

.1.  X  

Kansas  City,  Mo.  . 

Philadelphia,  Pa.. 
Chicago,  111  

shuU-r,  John  B  

Smith,  J.  F  

Stewart,  Thos.  J  

Philadelphia,  Pa.. 
.•r.  Col  

(!.  H  

David  

London  

TGEN   THERPAY. 

RATUS. 


B.  SOURCE  OF  CURRENT 

1.  Accumulator,  Capacity 

2.  Hirect  Current 

3.  Alternating  Current 

4.  Transformer 


C.  COIL 


D. INTERRUPTER 


E.  CROOKES  VACUUM-TUBE 


Variety 
or  Make 


Length 

•  .f  Spark-Gap 

(Parallel) 


1.  Mechanical      \i.  Mercury      1.  Non-regulating 
:i.  Wehnelt  4.  Caldwell      2.  Self-regulating 

5.  Simon  3.  Osmo-regulating 


IncheH 

Cm. 

' 

(2)  110  volts  H.  Q.  B  
Western  

12,  16,  18 
15 
10 

IS,  12 
8,12 
10 

10 
12 

30,  40,  45 
38 
25 

45,30 
20,30 
25 

25 
31 

1,*3,*(6)  variable  
2,3,  (6)  120  to  1200  

2,*3,  G.,  Q.,  H.  M  
2,  (4)  M.,  F  

(2)  110  volts                          Q           

1.2  

1,  2,  (4)  Q.,  M.,  G  
G.,  M.*  

(2  )  110  volts                          C  

1*  (6)  1200  

(3)  115  volts  Sch.,  K.  «fc  K.  . 

My  own,  (6)  variable  
3,4  
3  

1,  2,  (4)  F.,  G.*  

Will.,  W.  &  B. 

'  2,  (4)  G.,G.  &B  
2,3,  (4)G.,M  

2   (4)  M    .  . 

(2)  110  volts  

(2)  220  volts  K.,  W.  &  B.  .  .  . 

1,  K.,3,4  

1,  2,  3,  4,  (6)  300-3000*  
123   (6)  l^O  to  3000 

'1234*  

(Q  1  *                                     Vary*... 

(1)  14  v  30a-h     (2)  110 

40,20 

12,  15* 
18,12,12 
8,12 

12 
16 
10 

4,  " 

ta 

10,  18  * 
18-20 
18,20,12 
18,  24 
9,18 
16 

20,  12,  8 
20,12 
20,18 

9 
12,14,22 
12,  18 

90,50 

30,4^ 
45,30,30 
20,  30 

30 
40 
25 

10,  17% 
30 

25,45 
45-53 
45,51,30 
45,61 
23,45 
40 

50,30,20 
50,30 
50,45 

23 
30,35,55 
30,45 

9  a 

(3)  £». 
(9)  2°0  volts                        Coxe      home- 

1, 2,  3,  (6)  D.,  Gai  1   94*  

made. 
(1)  10  cells  21  volts.            Q.,Sch.,  K.... 
(3)  100  volts. 
(2)  110,  (4)  valve,  k.k.  .     W.  &  B.,  K.  & 
K.. 

(2)  100  volts 

K.  and  my  own  

(1)  some,  (2)  prefer,  3,  4.* 
2,  (4)  W.&B  

3 

3,4,  W  
123 

(2)  110  volts  R.,  G.  &  S  
(2)  110  v  •  (4  )  Gaiffe  .       Gaiflfe  

2  3  14   t&\  M 

(2)  Gaiffe  

2  3  

(1)  lO-'JO  volts  L.  <fc  N  
(2)  110  volts                  .   .    Q  

1  

(21  O     M      (31  G 

(1)  Queen  

2   (4)  Q    M     F  

(°)  70  volts                           A-N  

1,  (6)  600-2000  

23  

(2)  80  volts  Will  

1,  2,  3,  my  own,  (6)  3000- 
40,000. 
1,3  

1,  3*  

3   (4)  M    G  

<   L.,Sn.,  Q  
R.Mfg.Co.... 
(1)16  volts;    (2)   110  v.     L.,R.Mfg.Co.* 
(2  )  110  volts  

|l,  2,Q.,  M..F..G  
(4)  Q    G    M  &  W    . 

1  3 

1  4*  ... 

1,  2,  3,  4  1  2  

Sch.,  Ruhm.  .  . 

1    3    9    lt\  d     M     Mmi   . 

(2)  110  volts  Q  

1   3  

4*  

(2)  110  volts  Sch.,  Fes  
(1)  'JO  volts    R  

1,  3,  (6)  800  

123/4\  many  .  . 

1  

2,  (4)  Q  

(2)  110  v  •   (4)  Rotary'      Sch 

23... 

2,  (4)F.,  G.,M.  <feW  
2  (41  Q    G    M  * 

Mercury. 
(2)  110  volts  ."  Q.,  L  

1  3   (6)  600  ....            

234 

9  a  t*\  *... 

(2)    200  volts  A-N  

12 

30 

2,D  Bi-anodal  

TECHNIC    OF    RONT 


: 
~- 

} 

1 

1 

4 

1 

6 

7 

- 
1 

10 

u 

:-• 
U 

1! 

U 
H 

i: 
U 

U 

IB 
B 

B 
• 
M 

• 
• 

-•: 

-'• 
1 

.:! 

I.   V.M  11  M   Tri:i:   KMI-I 

II.  DISTANCE  or  ANODE  FROM  PATIKNT  s  Skis 

III.    Et|VIVAI.EN 

Superficial 

Sub- 
cutaneous 

De«p- 

-...!•  •! 

Soft  or  Low 
Vacuum 

Medium 

Hani  or  High 
Vacuum 

Superficial 

Sub 

Inches 

Cm. 

Inches 

Cm. 

Inches 

Cm. 

Inches 

Cm. 

Inch 

Soft  

Low  .... 
Low  .... 
Low  .... 

Very  Nil 
Very  soft 

Medium 

Medium 
Medium 
Medium 

Medium 
Soft  

Hard  ... 

High.... 
High.... 
High.... 

Hard  ... 

Medium 
or  hard. 

8 

5-9 
6-12 
5 

* 
•— 
2-5 

* 

20 

13-23 
15-30 
12% 

6 

8-12 
9-15 
12 

6-8 
6-8 

15 

20-30 
23-38 
30 

15-20 
15-20 

5 

12-30 
1-2-20 
20 

15-20 
12-15 
4-6 

* 

12% 

30-75 
30-50 
50 

B8-4M 

30-38 
10-15 

IK 

2-3 
3-6 
1 

4 

5-7^ 
7H-15 

2K 

._>_01 

:v-4i 
6-S 

13-20 
5-12 

4-8 
1X-2 

2-3 

10-20 
3-5 

5-7% 

•J-:;- 

Medium 

* 

Low  .... 

Medium 
soft. 

* 

Low  — 

Medium 

High.... 
Hard 

2-5 

* 

5-12% 

4-7 

* 

10-17% 

M 

* 

15-20 

1-3 
3-5 

iM*a 

i 

2%-7% 

754-13 
3K-6 

2% 

4-C 

2-1 

* 
Medium 

* 
High.... 

* 
S-6 

* 

7%-15 

6-10 

15-25 

6-20 

15-50 

8 
11-21 

M 
3 

4 
7-12 

1 
*-l 

Of 

K-i 

M 

20 
3-6 

H 

7% 

10 
17%-30 
2% 
l*-2% 
3% 

H-2X 

7%-10 

6 
2-8 
3 

4 

* 

15 
5-20 
7% 

10 

10-12 
8-20 
10 

8 

* 

25-30 
20-50 
25 

B 

IK 
6 

7-1 
1-1' 

•t 

IV 

i--" 

8 
5 

6 

* 

20 
13 

15 

Low  .... 

Medium 
Medium 

High.... 
Hard  ... 

Soft  
G..Q... 

Soft.... 

* 

Low  ... 

Medium 
low. 

Soft.... 

Low  .... 
Low  — 
Q-*  

Soft  to 
Bottom 

High.... 
Same  ... 
Medium 
* 
Medium 

Medium 
high. 

Medium 

Medium 

M.-.limn 

Medium 
•oft. 
Medium 

High.... 
Q.M.&W. 
Hard.  .  .  . 
* 
High.old 

4-10 
7-9 
6 

10-25 
18-23 
15 

4-10 
8-12 
10 

10-25 
20-30 

-'.-. 

10-20 
12-18 

ia-15 

25-50 
30-46 
8048 

5-7 
10 

10-12 
8-10 
8-10 
10-15 

13-17% 
25 

j:,-::n 
20-25 
15-25 

•  n 

12-15 

u 

12-18 
10-14 
10-15 
15-30 

30-38 
45 

30-45 

j.v:;:, 

s04e 

38-75 

Hard  ... 

High.... 

Medium 
high. 
Medium 

Medium 
to  high. 

8 

6-10 
M 
M 

3-8 

20 

15-25 
15-20 
15-20 
7%-» 

1 
>*-l 

2% 
1^-2% 

*•» 

lM-2« 

1-. 

THERAPY— Continued. 

NIC. — Dosage. 


M.K  LENGTH  OF                             I  V.  <  TRUEST 

PI.HYF1I 

.i.'|.>iu.i.i|iililS 

V.  PENETRATION 

VI.  CHEMICO- 

I'HYSIi'AL 

VII.   PHOTOMETRIC  COMPARI- 

feme 

Cm. 

Deep-scat.  •<! 

Primary 

Coil 

Secondary 
Coil 

1.  liailinrliriiiiiniiirti-r 

1  Iti'llnist) 

2.  Pcwtnimctcr 
(Walt..  . 

r           °JJ 

f         "3 

5  -i  -^  i  .^  =  :5 
>-  —  •=  -/.  —  -  — 

C«           3" 

1.  Kiuli.i-Activitv 
-'.  Artificial  Ucbl 
::.  S'lcniuni  crll 
(Uiihincr  Levy) 
1.  I'liii/alioii 
1  i.u.klin) 

luorescenco  nf 

T.ll.r 

'i'-e  of 
A  node 
lermomrtcr 

(Kohl.-r) 

Inches 

Cm. 

Volt 

AIIIJP. 

Millianip. 

&"<      •<      H 

—  '         Tl         CO 

',-11 
fc-20 

4-6 

8-12 
5 

10-15 

11-14 
20-30 

5 

1  .   YPS 

110 
110 
110 

* 
115 
110 

220 
220* 

1^-24 

2  

•2  

1 

1,2  (red)  

3-6 

2-12 
5-8 
3-6 

1-2* 
5-10 

1 

2  

(1)  3  to  8  

10-20 

6-8  + 

i-s 

3-6 

15-20+ 
10-20 

7^-15 

15-60 

4-10 

1   2  

1  2  

4  

* 

3*  .... 

1*  

* 

2*  

1*  

10-15 
5-10 

5  + 

8-14 
3-5 
4-6 

12^4- 

20-35 
7^-13 
10-15 

3-15 
1-5 

* 

60 
21 
80-120 

5-15 
2^-5 

4-8 

(1)  About  7 

9 

(1)  partly, 
(2)  red  hot. 
1,  (2)  on  some 
tubes. 

0.5-2.0 



(2)  4-6 

1 

2 

12 
2-J 

2^-5 

8 

6-8 
7-12 
4 
2-4 
3 
1-10 
5-6 

30 
5-10 

20 
15-20 

10 
5-10 

2^-25 
13-18 

70 

3 

0.2-0.6 
Gaiffe* 

1-6 

1*  

2*  4* 

2* 

19  

4-7 

15 
.13 
5 

5 
94-10 
b-13 

Yes 
Yes 

1 

2 

20 

4-10 

70 

2-8 

1 


Yes 

1.  2*  ... 

..    1  .. 

110 
110 

2-3* 
2-5 

* 
1 

(1)  3  superficial 
6  deep. 

110 
110 

110 
20 

no 

110 

5 
8-8 

2-4 
2 
5 
3-6 

19                                                                   .     :  .  .  . 

* 

i  * 

1*... 

-V- 

2-4 

5-10 

..    1.  2*  ... 

1*  .. 

** 

2-1 

5-10 

Yes 

*• 

1.  2*  

di  l-i  orCB.. 

.1,2,  partly... 

TECHNIC   OF    RONTGE1 

3.     PRACTICAL 


T 

: 
3 

I 

I 

s 

\ 

1 

•••• 
; 

B 

6 

- 
g 

u 

u 
a 
u 

u 
u 

!• 

B 
U 

IS 

no 

B 

a 
• 

a 

• 

8 

a 
a 
a 

::l 

DOSAGE  AND  CI.ISICAI,  A- 

1.  Do  you  vary  the 
length  of  treat- 

iiit-nt  '.' 

1!.  What   i"   your  aver- 
age length  of  treat- 
ment ?    How  often 
j«er  week  ? 

3.  Do  YOU    protect 
healthy    part, 
and  h»w? 

4.  What  is  the  I't-st  in- 
dication tiMlisron- 
tillllr     trratlllrllt  ? 

Is  it  a  iiiilil  i-r\- 
tlii-ma? 

.">.  AVhrii   iln   V.MI    IK 
lieve  an  rrytlu 

ma  i-  • 

Yes                   

5  minutes;  thrice  

Varies;     daily    to    3 
weeklv. 
«                     

Lead-foil  
Yes  *  

Yes  
Mild  ervthema  

*  
Maliirnancv  

VOB 

Yes 

Yes  shield  

Krytlu-ma  generally  .  . 
Yes  

Tanning  sometimes.  .  . 

Superficial  < 
Lupus    

Voa 

10;1  to3  

Tin-foil  

*  

When  indicated  
Yes  * 

Lead  * 

*  Yes....  

Vcrv  rarelv  

Yes  *    

*               

*                 

V«B 

1%  minutes  ;  thrice  .  .  . 
5-10;  daily  to  monthly 

10  minutes;  daily  

5  minutes;  thrice  
3-5  minutes  ;  1-3  days. 

Yes,  for  eye  and  hair  . 

*  VITV  mild  

*         

Y>  - 

Lupus  *  

Yes*  

Yes*  
Lead          

* 

Yes 

Slight  dermatitis  

\l\vftvs  

Yes 

*  Prefer  

Usually*  

YP« 

Lead 

*  Yes           .         

10  minutes  ;  twice  
Varies                      

Lead-foil  
Lead  *           

Yes  

Usually  

Yes 

Yes  

*                

*               

Yes 

Lead 

?  Yes 

* 

Yes               

10  minutes  ;  thrice  — 

15  minutes  ;  2-3  times 
20  minutes  ;  thrice  — 
10  minutes  ;  1-7  times  . 
Varies  *             ... 

Tin-foil  

Hy  perse  mi  a  some- 
times. 

Yes  *                     

Skin  k-sions  

Yes  

No  

No  
Lead 

Recovery  *  

g  $ 

*  

* 

Yes  

Yes  

Yes* 

*                                     *  

Yes  

10-30     minutes;     1-6 
times. 

10-15  minutes  ;  thrice. 
5  minutes;  '2-3  times.  . 

9  minutes*  

Lead 

Yes  *                                  *  

Yes*  

Tin-foil 

Y|.»                                     *  

Yes  

Lead-foil  
Yes*..  .  . 

Yea*  

*  

*          

Yes  

Yes  

!.*>  minutes  ;  3-6  times. 

Usually  

Yes  

Lead 

Yes  

Id  mi  link's;  tliricc  ... 
10-15  minutes  ;  thriee. 

Lead  and  glass  shield 
Ix-uci 

*                       

Yes*  

• 

* 

THERAPY— Continued. 

PLICATION. 


i  N  RAY  DERMATITIS 


What  i<  your  treatment  for  the  acute  and  chronic  forms  of  the  above? 


In  the  acute  form,  a  non-irritating  unguent,  as  lanolin,  prevents  incrustation  and  is  strongly  recommended. 
For  deep,  sloughing  burns,  clear  up,  and  stimulate  with  the  galvanic  current.  If  rebellious  to  treatment, 
excise-  nnd  skin  graft. 

This  depends  entirely  on  the  severity  of  the  dermatitis  and  the  idiosyncrasy  of  the  patient. 
Discontinue  treatment. 

Dry  heat.  Simple  ointments,  sparingly.  Salicylic  collodion  for  scales;  for  ulcers,  argyrol  (20  to  30  per  cent, 
solution);  cover  latter  with  silver-leaf. 

I  have  none,  nor  do  I  know  of  any. 

Lime-water,  lanolin,  lard,  equal  proportions  (Dr.  C.  \V.  Allen's  formula). 

Avoidance  of  the  X-ray  atmosphere.  For  acute  cases,  Liquor  Burowii  and  15  per  cent,  boracic  lanolin — 
Buspenatom* 

Never  had  any  case  of  dermatitis  to  treat.    Have  nothing  specially  adapted  to  recommend. 

Varies.  If  superficial  and  painful.  I  use  liq.  plumb,  subacetat.  dil.;  much  pain,  lanolin  with  a  trace  of 
cocaine  and  surrounded  by  an  oleaginous  material  on  lint,  the  whole  protected  by  absorbent  cotton. 

Acute  :  Cease  treatment ;  allay  itching  with  a  saturated  solution  of  sodium  bicarbonate.  Chronic:  Cleanse 
with  a  saturated  solution  of  'potassium  permanganate  and  apply  plain  sterile  vaseline  on  sterile  gauze. 

For  the  acute  form,  a  lead  lotion.    Have  found  nothing  satisfactory  for  the  chronic  form.* 
Castor  oil  and  Basham  mixture. 

Acute:  Lanolin  and  picric  acid.  Chronic:  Excision  and  skin  grafting  for  ulceration.  Lanolin  in  cases  of 
parched  condition,  lor  circulation  and  cutaneous  nutrition.  High-frequency  currents,  for  stimulation  of 
the  circulation,  locally. 

For  the  acute  form,  protection  from  air  and  mechanical  injury. 
The  usual  methods  in  vogue. 

The  lesion  should  be  unexposed  and  be  kept  away  from  the  rays.  The  application  of  a  thick  ointment  of  the 
i ixii It-  of  zinc.  The  effluve  from  a  high-frequency  machine. 

Stearate  of  /inc.  with  ichthyol  10  per  cent.,  to  prevent  and  allay  dermatitis  and  itching.  For  chronic  cases, 
sterile  gauze  and  normal  salt  solution  with  orthoform  for  pain. 

Paint  the  part  with  an  aqueous  solution  of  resorcin  (25  per  cent.),  once  daily.  For  itching,  immerse  in  hot 
water,  the  hotter  the  better.  In  the  chronic  form,  removal  of  the  patient  irom  X-ray  influence  for  a  year 
or  eighteen  months. 

Cessation  of  irradiation.     Lead  lotion. 

Lanolin. 

Meet  the  symptoms  as  they  arise,  the  same  as  you  would  in  any  other  condition. 

The  treatment  recommended  is  a  lengthy  one,  and  is  described  fully  in  the  addendum  (vide). 

Discontinue  X-ray  therapy.    Treat  as  any  other  burn.    Avoid  all  irritating  applications. 

Olive  oil.  listerine.  and  bismuth  subnitrate.  equal  parts  of  each. 

Pain  has  been  relieved,  in  a  few  instances,  by  an  ointment  composed  of  ten  grains  each  of  orthoform,  resorcin, 
and  calomel,  in  one  ounce  of  cold  cream. 

No  active  treatment  is  recommended.  Avoid  the  X-ray  atmosphere.  The  operator  is  advised  to  remain  in 
a  room  thirty  feet  from  the  tube,  and  to  place  himself  behind  an  iron  screen  one-fourth  of  an  inch  in 
tblcknev. 

Had  no  occasion  to  employ  any.* 

Simple  dry,  or  absorbent,  aseptic  dressings.    Zinc  oxide  ointment. 

Avoid  active  treatment.    Zinc  oxide  to  allay  the  itching. 

Acute :  Removal  from  the  exciting  cause ;  soothing  and  antiphlogistic  drugs  and  preparations.  Chronic : 
Avoid  the  rays,  developing  fluids,  and  cold  water:  apply  hot  water,  bland  unguents,  and  mild  high- 
frequency  currents.  For  deep  Koiitgen  ulcers  apply  caroid  to  slough  and  treat  as  local  gangrene. 


ROXTGEN  RAY  TREATMENT  CHART                           No. 

Name 

Address,  or 

190 

Dept.  and  Ward 

Historj 

Ag>- 

Sex 

Part  affected,  Extent, 
Duration.  rl<-. 

Macroscopic. 

1 

Microscopic 

Diagnosis 

Previous  Treatment 

I 

_ 

1! 

.= 
I 

!' 

-~  '- 

i  3 

\  ; 

•s  -s  §• 

:     ja  =  CJ 

!  til 

:      -,  «    5. 
.     w        a: 

8  3   S 
3  i  ^ 

•S   <    5 

3  -3  I 

Months 

1 

Minutes 

Methods  Used  in 
Measuring  Dose,  i.e. 
Quality  and  Quantity 
of  Ray 

Remarks  and  Results 

3   Inch 

Cm.  Inch 

Cm. 

Totals. 

Reduced  from  the  size  of  original  clinical  chart. 


INDEX 


In  order  to  facilitate  reference,  the  various  diseases  and  their  treat- 
ments are  grouped  under  four  headings, — X-rays  in  the  treatment 
of,  radium  treatment  of,  high-frequency  currents  in,  and  electricity  in 
diseases  of.  Thus,  in  studying  the  action  of  the  Rontgen  rays  on  acne, 
the  reader  will  refer  to  X-rays  in  the  treatment  of  acne.  The  very 
arbitrary  and  artificial  division  of  the  headings  electricity  (faradism, 
galvanism,  static  current,  etc.)  and  high-frequency  currents  is  simply 
an  index  convenience. 


Abbe,  his   statistics   on   renal  skia- 

graphy 353 

on  radium  strength  and  radium 

therapy 507 

Abrams,  on  the  causes  of  restriction 

of  the  diaphragmatic  wave 310 

Accelerator,  for  photography 223 

Accessories  to  the  static  machine. . .     52 

Accumulators 41 

Action  of  light  on  plants 511 

of  the  X-rays  on  bacteria. .   389-394 

Acute  X-ray  dermatitis 400 

Adamson,  on  the  X-ray  treatment  of 

ringworm 450 

Advantages  of  fluoroscopy 213 

of  print  in  skiagraphy 231 

of   stereo-skiagraphy 251 

of  X-rays  in  the  differential  di- 
agnosis   of    complicated 

fractures 257 

in    the    treatment    of    tra- 
choma     487 

Albers-Schonberg,  on  the  consump- 
tion of  tubes 198 

on  the  four  degrees  in  vac- 
uum tubes 195 

on  the  likelihood  of    X-ray 

dermatitis 402 

on  sterility  caused  by   the 

X-rays 412 

Alternating  current 45 

Ampere 37 

Ampere-hour,  definition  of 42 


Analgesic  action  of  the  X-rays 493 

Anatomy,  value  of  the  X-rays  in,  252-255 
Aneurisms,  aortic,  their  diagnosis  and 
differential  diagnosis    skiagraphic- 

ally 333-335 

Apostoli  and  Oudin,  on  the  treatment 

of  X-ray  dermatitis 411 

Apparatus    and    method    of    X-ray 

therapy 420-427 

used  in  dental  skiagraphy 370 

Arm  bath 79 

Arneth,  on  the  blood-changes  induced 

in  leuksemia  by  the  X-rays 486 

Ascending  current 67 

Ausset  and  Bedart,  on  the  X-rays  in 

tuberculous  peritonitis 480 

Author's  cases  of  cerebral  skiagraphy .   281 
of   incipient  pulmonary  tu- 
berculosis   diagnosed    by 

the  X-rays 317,318 

of    mammary    carcinoma 

treated  by  the  X-rays  465-467 

examining  box 236 

head  rest  for  cerebral  skiagraphy  278 
method  of  irradiating  cases   of 

trachoma 487 

cases  of  uterine  cancer.   470 
of  skiagraphing  rectal  imper- 

foration 345 

of  treatment  of  chronic  X- 

ray  dermatitis 409 

report  on  irradiation  of  cases  of 
epilepsy 495,  496 

527 


.VJS 


INDKX. 


Author's  table  for  skiagraphy,  stereo- 
skiagraphy,  and  X-ray  treat- 
ment   200,248 

tank 228 

tube-holder 201 

views  in  regard  to  the  limitations 
and  value  of  the  X-rays  in  car- 
cinoma   464,  4(>o 

Auto-conduction  by  the  solenoid 147 

B 

Bacteria,  action  of  the  X-rays  on  389-395 

Bactericidal  action  of  radium 501 

Bar  and  Boulle\  on  red  light  treatment 
of  X-ray  dermatitis 411 

Barnum,  on  the  X-ray  treatment  of 
keloid 490 

Barrel's  method  for  the  localization  of 
foreign  bodies 300 

Barthelemy  and  Oudin,  on  the  X-rays 
in  hypertrichosis 448 

Batten,  his  method  of  treating  ring- 
worm by  irradiation 450 

Bauer's  vacuum  tube 194 

Beck,  on  microscopy  of  adeno-carci- 

noma  after  irradiation 418 

on  skiagraphy  in  hepatic  condi- 
tions   348 

osteoscope  of 196 

Becquerel,  studies  of,  with  radio-ac- 
tive substances 498,  499 

Behavior  of  light  on  animals  and  man  512 

Berton's  experiments  with  the  X-rays 
on  the  Klebs-Loffler  bacillus 389 

Bishop,  on  exophthalmic  goitre 121 

on  X-ray  treatment  of  trachoma  488 

Blackening  of  the  tube 197 

Blackmar,  on  the  action  of  the  X-rays 
in  malignant  disease 417 

Blondlot,  R.,  on  velocity  of  propaga- 
tion of  X-rays 167 

Blue  light  as  an  anaesthetic 520 

Boggs,  on  the  X-rays  in  tuberculous 
adenitis 481 

Boido  and  Boido,  their  reports  of  irra- 
diation in  cases  of  pulmonary  tuber- 
culosis   478 

Bordier,  on  dermatitic  changes  caused 
by  the  X-rays 405 

Box-cover  for  X-ray  tubes 202 

Brant h,  his  method  of  irradiation  in 
cases  of  epilepsy 496,  497 


Brewster's  refracting  stereoscope  for 

stereo-skiagraphy 249 

Brown  and  Osgood,  on  sterility  due  to 

the  X-rays 412,  413 

Brush  discharge 57 

Bullitt,  his  comparison  between  the 
X-rays  and  the  surgical  treatment 

of  tuberculosis 481 

Bunsen  cell 63 

Burr,  reports  of  cases  by,  on  bony  con- 
genital deformities 27.5 


Caldwell  and  Simon's  interrupter.  .  .  .    178 

Cald well's  cavity  vacuum  tube 424 

Campbell,  on  the  radiotherapy  of  acne  452 
Cannon's  studies  on  the  stomach  dur- 
ing digestion  as  viewed  fluoroscopi- 

cally 342 

Capp  and  Smith,  on  a  review  of  the 
advancements  made  by  irradiation 

in  lymphatic  leukaemia 4s"> 

Carabelli  and  Luraschi,  on  the  X-rays 

in  prostatic  hypertrophy 492 

Care  of  battery 64 

of  photographic  plates 222 

of  static  machine 51 

of  vacuum  tube 196, 197 

Catalysis 98 

Cataphoresis 75 

its  bearing  on  galvanism 75 

Cataphoric    electrodes,    for   high-fre- 
quency currents 144, 145 

Cathode  rays,   chemical  and  photo- 
graphic effects  of 159 

deflection  of 185 

fluorescence  and  phosphores- 
cence of 159 

physiological  effects  of 159 

production  of 158,  185 

radiability  of 158 

rectilinear  propagation  of ...    187 
reflection,     refraction,     and 

polarization  of 159 

theories  to  explain  the  exist- 
ence of 159 

Causes  and  prevention  of  faulty  nega- 

tivos 231 

of  X-ray  dermatitis 398, 399 

Cautery  batteries 69 

Cells,  Bunsen 63 

charging  the 64 


I X 1  )EX. 


529 


Cells,  galvanic 62 

"group"  arrangement  of 41 

Grove 63 

Leclanche 64 

"  parallel "  arrangement  of .  ...   40,63 

"series  "  arrangement  of 40,  63 

types  of 63 

wet  and  dry 63 

Central  galvanization 69 

pneumonia,  value  of  the  X-rays 

in 320 

C.  G.  S.  system 36 

Chain-holder  for  the  static  machine ...      53 
Changes   induced  in  diseased  tissues 

by  the  X-rays 415^419 

Chart  of  static  modalities 60-61 

Chemical  and  photographic  effects  of 

radium 498,  499 

Chromoradiometer    of     Bordier,     for 

measuring  X-ray  dosage 433 

of  Holzknecht,  for  measuring  X- 

ray  dosage 432 

Chronic  X-ray  dermatitis 400 

Cinemato-radiographs  of  the  heart .  .  .   329 
Clark,  on  the  therapeutic  action  of 

the  X-rays  in  cancer 471^i73 

Classification  of  radio-activity 501 

of  radium  rays 501 

Closure  of  the  bladder,  shown  skia- 

graphically 360 

Codman,  on  fluoroscopy  and  skiagra- 
phy  in  a  study  of  joint  mechan- 
ism   254,255 

on  latent  stage  of  X-ray  derma- 
titis    401 

on  pathology  of  X-ray  dermatitis  404 
on  relationship  of  static  machines 

and  coils  to  X-ray  dermatitis .   403 
Coil.   (See  Induction  coil.) 
Coleman,  on  electricity  in  many  oph- 
thalmic affections 136, 137 

Coley,  conclusions  of,  on  the  value  of 
the  X-rays  in  malignant  disease .  .  .   476 

Commutator 172 

Compression  diaphragm 202 

disadvantages  of 203 

Condenser 171 

Condenser  electrode 145 

Conditions  necessary  for  success  by 

Finsen's  method 520 

Conductive  currents 58 

Conductivity 38 

34 


Connal,    on   high-frequency   currents 

in  dulness  of  hearing 154,  155 

Connections  of  a  galvanic  battery.  .  .      62 

Construction  of  induction  coil 171 

Continuous  current 45 

Contremoulins'    measurement   of   X- 

ray  dosage 439 

on    the    skiagraph    in    pelvime- 

try 363-365 

Convective  currents 57 

Cossar's  cavity  vacuum  tubes 424 

Coulomb 38 

Courtade,  radiometer  of 438 

Covell,    on   a   case    of  asthma   with 

fibroids,  cured  by  galvanism 126 

Crookes,  experiments  on  radio-active 

substances 499 

his  assertion  that  matter  is  radi- 
ant     157 

spinthariscope,  for  studying  the 

fluorescence  of  radium 500 

tube 187 

tube  for  therapeusis 422 

(See  Vacuum  tube.) 
Crypto-radiometer    of    Wehnelt,    for 

measuring  X-ray  dosage 431 

Cryptoscope 199 

examination  with 211 

Curie,  Professor  and  Madame,  on  the 

study  of  radio-activity 499,  500 

Current  going  to  the  primary  coil,  in 
the  study  of  X-ray  dosage 427 


Dally,   his    classification   of    shadow 

quality  with  percussion  note ..   319 
on  pleurisy  with  effusion,  studied 

skiagraphically 322 

Dark  room  in  photography 221 

D'Arsonval,   on  high-frequency  cur- 
rents     138,141 

Data  on  the  negative  in  skiagraphy.  .   218 
Davidson,  contact  rotary  interrupter 

of 174 

his  method  of  localization  of  for- 
eign bodies  in  the  eye 295-297 

Davies,  experiments  with  the  X-rays 

on  bacteria 389 

X-ray  study  of  gravid  uteri ....   366 
Definitions    of    electro-therapeutic 

terms 67 

Degeneration  of  muscles 90 


L\Di:x. 


Dermatitis.  (See  X-ray  dermatitis.) 

Dermo  or  iron  electrode  lamp 516 

Descending  current 67 

Destot's  views  on  dermatitic  changes 

caused  by  the  X-rays 405 

Developers  in  photographic  work  222,  223 

Developing  papers 232 

Diagnosis  and   differential   diagnosis 
of    aortic    aneurisms    by    the    X- 

rays 333-335 

Diaphragm  (skiagraphic) 202 

compression 202 

its  disadvantages 203 

lead  iris 221 

Differentiation  between  ordinary  pho- 
tograph and  skiagraph 214 

Disadvantages    of    compression    dia- 
phragms     203 

of  fluoroscopy 214 

Disan's  method  of  fluoroscopic  exam- 
ination of  the  normal  heart 324 

Disk  interrupter 174 

Disruptive  currents 58 

Distance    of    the    tube,    for    X-ray 

treatment 424 

from  the  plate 219 

Dodging 232 

Dorn,  Professor  E.,  on  visibility  of 

X-rays 167 

Dosage  of  the  galvanic  current 67 

of  the  static  current 56 

of  the  X-rays 426,  427 

(See  X-ray  dosage.) 

Dry  cells 63 

Drying  the  negative 228 

Du  Bois-Reymond,   his  law  for  the 
electrical    stimulation    of 

muscles 94 

on  muscular  contraction  fol- 
lowing electrical  irrita- 
tion of  motor  nerves 92 

Ducretet's  self-regulating  tube 192 

Dunham,  selenium  cell  of,  for  X-ray 

dosage 439 

Duration  and  course  of  X-ray  derma- 
titis    406,407 

of  exposure  in  irradiation 425 


Eder  and  Valenta,  on  the  degree  of 

vacuum  of  tubes 195 

Edsall,  Pancoast,  and  Musser,  on  the 


asserted  secondary  results  occurring 
after  irradiating  cases  of  leukaemia  486 

Effects  of  light  on  bacteria 511,  512 

of  radium  on  the  eye 502 

on  the  nervous  system .   502 

Effluve 145 

Einhorn,  his  observations  on  radium 

therapy 506 

on  transillumination  of  the  stom- 
ach    341 

Electrical  currents,  effects  of,  on  sen- 
sory cutaneous  nerves     95 
on    the    abdominal  or- 
gans    97-98 

on  the  head 97 

on  the    sensory  nerves 

of    muscles 95 

on  the  skin 97 

on  the  special  senses .   95  -96 

on  the  spinal  cord 97 

on  the  sympathetic  sys- 
tem      96 

pathological   physiology   of, 

in  disease 98 

douche  bath 79,  80 

energy,  sources  of 39 

mains 45 

reactions    of    nerves    of    special 
sense     and     of     the     sensory 

nerves 91 

souffle 58 

stimulation  of  muscles 94 

wind 58 

Electricity  as  a  part  of  the  medical 

curriculum 31,  32 

for  aneurism 127-128 

historical  sketch  of  the  rise  of .   29-31 

in  cutaneous  affections 99-103 

in  acne 99 

in  alopecia 99 

in  cutaneous     anaesthe- 
sia     101 

in  eczema 99 

in  furuncles     and     car- 
buncles     102 

in  herpes  zoster 101 

in  hypertrichosis 100 

in  moles  and  warts.  ...    102 

in  naevus 102 

in  port-wine  mark 102 

in  prurigo 101 

in  pruritus 99 


IXDEX. 


531 


Electricity   in   cutaneous   affections  : 
in  psoriasis  and  pity- 

riasis 101 

in  ringworm  and  sclero- 

derma 101 

in  diseases  of  the  articular  sys- 
tem     105-107 

in      chronic      articular 

rheumatism 105 

in  fibrous  ankylosis.  .  .  .    106 

in  gout 106 

in  hydro-arthritis 105 

in  rheumatoid   arthritis  105 

in  synovitis 105 

in  tuberculous    arthri- 
tis     106-107 

in  diseases  of  the  digestive  sys- 
tem     107-111 

in  constipation :    108 

in  dilatation   of   the 

stomach 107 

in  enteritis 109 

in  fissure  of  the  anus.  .    110 

in  hemorrhoids Ill 

in  nervous  dyspepsia. .  .    108 
in  prolapse  of  the   rec- 
tum     110-111 

in  stricture  of  the  rec- 
tum     Ill 

in  vomiting 107 

in  diseases  of  the  genito-urinary 

system 111-116 

in  impotence 116 

in  incontinence  of  urine  115 

in  nephritis 116 

in  orchitis 116 

in  paralysis  of  the  uri- 
nary bladder 114 

in  prostatitis 113-114 

in  spermatorrhoea 115 

in  stricture  of  the  male 

urethra 111-112 

in  diseases   of  the  nervous  sys- 
tem     116-122 

in  cephalalgia 117 

in  chronic  spinal  muscu- 
lar atrophy 119 

in  epilepsy 119 

in  exophthalmic  goitre.    120 

in  hemiplegia 118 

in  hypochondriasis   and 
melancholia. .  .120 


Electricity  in  diseases  of  the  nervous 

system :  in  hysteria ..    120 

in  insanity 120 

in  insomnia 119 

in  locomotor   ataxia.  .  .    119 

in  neuralgia 116-117 

in  neurasthenia 120 

in  paralysis,  from  arse- 
nic, etc 118 

from  rheumatism . .    118 

from  syphilis 118 

in  paraplegia 118 

in  peripheral  neuralgia.    118 

in  poliomyelitis 119 

in  sciatica 118 

in  tic  douloureux 117 

in  gynaecology 122-127 

in  amenorrhoea 124 

in  chronic  metritis 125 

in  dysmenorrhcea 124 

in  fibroid  tumors 124 

in  ovarian  tumors 124 

in  periuterine  haematocele.  .    125 
in  post-part um  hemorrhage .    125 

in  slow  labor 126 

in  stenosis    of    the    cervical 

canal 125 

in  subinvolution    and    atro- 
phy     125 

in  urethral  caruncle 125 

in  vomiting  of  pregnancy.  .    126 

in  muscular  affections 103-105 

in  muscular    contrac- 

tures 104 

in  myalgia 103 

in  my  asthenia  gravis  .  .    105 
in  secondary  hemiplegic 

contractures 104 

in  torticollis 104 

in  writers'  cramps .   103-104 

in  ophthalmology 134-137 

in  blepharospasm 134 

in  cataract 135 

in  diseases  of  the  lacrymal 

canal 135 

in  oculo-motor  paralysis. .  .    134 

in  retinal  anaesthesia 135 

in  various  ophthalmic  affec- 
tions (a  summary).  ..    136,137 

in  otology 131-134 

in    chronic  suppuration  of 
the  middle  ear. . .  .    131 


INDEX. 


Electricity  in  otology:  in  deafness  of 

auditory  nerve  origin  131 

of  hysterical  origin.  ...  134 

in  otalgia  of  neuralgic  origin  134 
in  pruritus  of  the  auricular 

canal 134 

in  stricture  of  the  eustachian 

tube 134 

in  tinnitus  aurium . .  132, 133, 134 
in  rhinology  and  laryngology  129-131 
in   anaesthesia    of    the 

pharynx 130 

in  anosmia 130 

in  asthma 131 

in  atrophic  pharyngi- 
tis   130 

in  atrophic  rhinitis 129 

in  laryngeal  fatigue.  ...  130 

in  <>/;i-ll:i 129 

in  pharyngitis 129 

nature  and  properties 34 

Electrodes,    for    cataphoresis,    with 

high-frequency  currents.  .    144,145 

for  galvanic  battery 66 

for  laryngology  and  rhinology  .  .    129 

for  prostatic  hypertrophy 113 

for  static  applications 52 

glass  vacuum,  for  high-frequency 

currents 143,  144 

Electro-diagnosis,  hints  for  practical 

testing  in 89 

rules  to  be  followed  in 81 

Electrolytic  interrupters 175-178 

Electro-magnetic  or  "absolute"  C.  G. 

S.  units 37 

Electro-magnets 34 

Electro-motive  force 37 

of  the  static  machine ...     52 

Electro-physiology 92 

Electro-static  units 36 

Electro-therapeutic  terms,  definitions 

of 67 

Electrotonus 94 

Ellis,  on  tissue  changes  due  to  the  X- 

rays 418 

Envelo  developer 227 

Erb's  method  with  electrical  applica- 
tions in  epilepsy 119 

Essential  features  of  Crookes'  vacuum 

tube 188 

Evolution  of  the  X-rays 156, 157 

Examinations  with  the  cryptoscope . .   211 


Exner,  on  the  mode  of  retrogression 
of  cancer  metastases  under  radium 

therapy 504 

Explosion  of  the  tube 198 

Extra-oral  method  in  dental  skiag- 
raphy 371 

F 

Factors  varying    the  time  of    X-ray 

exposure 220 

Farad 38 

Faraday's  laws 169 

Faradic  current,  as  a  diagnostic  agent     74 

as  a  therapeutic  agent 74 

method  of  application 73 

Ferguson,    on    the    radiotherapy    of 

mammary  carcinoma 469 

Ferris,  on  the  X-ray  treatment  of  pso- 
riasis    457 

Filters,  as  prophylaxis  against  X-ray 

dermatitis 407 

for  X-ray  work 426 

Finsen,  his  experiments  with  light  on 
acquired   pigmenta- 
tions    513 

with  red  light 517,  518 

method  of,  with  concentrated  arc 

light 515,  516 

treatment  of  smallpox 519 

Fixing 227 

bath,  acid  chrome 227 

Fluorescence,  its  application  in  dis- 
ease    442,443 

its  natural  and  artificial  produc- 
tion in  the  human  body 441 

of  radium 500 

of  the  screen,  for  measuring  X- 

ray  dosage 440 

of  the  tube  and  appearance  of  the 
electrodes    for    measuring    X- 

ray  dosage 440 

Fluorometer  of  Williams,  for  measur- 
ing X-ray  dosage 438 

Fluoroscope 199 

method  of  examination  with.  . . .   210 
Fluoroscopic  examination  of  biliary 

calculi 346-348 

of  costal  angle 309 

of  diaphragm,  in  health  and 

disease 308, 310,  311 

of  heart.  .   308, 311,  325,  329,  332 
of  liver. .  .   346 


INDEX. 


533 


Fluoroscopic  examination  of  lungs  306, 308 

of  spleen 348,349 

of  stomach 338-341 

(See  Skiagraphy  and  the  X-rays 
in  the  treatment  of  various 
diseases.) 

Fluoroscopy 210 

advantages  of 213 

disadvantages  of 214 

positions  of  the  tube  and  patient 

for 212,  213 

preparation  of  the  patient  for. ...    211 
size,  shape,  and  intensity  of  the 

image  in 213 

Foreign  bodies  and  their  localization.   285 

in  the  eye 289 

in  the  genito-urinary  tract .  .    288 

in  the  intestines 288 

in  the  larynx,  trachea,  and 

bronchi 288 

in  the  oesophagus 287 

in  the  stomach 288 

their  localization  by  Barrel's 

method 300 

by  Davidson's    method 

295-297 

by  Fox's  method 298 

by   Grashey's     method 

303-305 
by  Grossman's    method 

297,298 

by  Harrison's  method .  .   302 
by  Leonard's  method..   302 

by  punctograph 299 

by  R6my's  method 300 

by  screen  method 299 

by Shenton's  method..   301 
by  Sweet's  method  290-295 
by  tr  iangulat  ion  met  hod  303 
Fox,  his  method  of  localizing  foreign 

bodies  in  the  eye 298 

on  the  treatment  of  retinal  anaes- 
thesia by  voltaic  alternatives.  .    135 
Fractures  and  dislocations.     (See  X- 

rays  as  a  diagnostic  agent.) 
Franklin,  his  views  on  the  ionization 
of  confined  gases  for  use  in  X-ray 

dosage 436 

Frequency  of  X-ray  exposure 426 

Freund,  on  dangers  of  X-ray  therapy  403 
on  fever    production    in    X-ray 
dermatitis.  .  .   405 


Freund,  on  hypertrichosis 447 

on  lupus  vulgaris 444 

radiometer  of 435 

X-ray  action  on  diseased  tissue. .  416 

Friedlander's  interrupter 177 


Galvanic  battery 62 

care  of 64 

charging  the  cells  of 64 

connections  of 62 

polarity  of 64 

(See  Cells.) 

current 39 

dosage  of 67 

Galvanism 62 

Galvano-faradic  box 67 

Galvano-faradization 69 

Galvanometer 66 

Gassiot,    experiments    of,    with    the 

Ruhmkorff  coil  instead  of  cells  .  .  .    156 
Gassmann,   on   blood-vessel   changes 

due  to  the  X-rays 397 

Gassmann  and  Schenkel,  on  dermati- 
tis due  to  the  X-rays 396 

Geissler,  Heinrich,  on  glow  discharges  156 
General  reduction  of  the  negative.  . .  .   230 
Geyser,  on  X-ray  treatment  of  tra- 
choma    488 

Gilchrist,  remarks  of,  on  dermatitic 

areas  due  to  the  X-rays 395 

Gill,  on  cataphoresis 75-77 

Glass,  plates  of,  for  static  machines.  .     52 
vacuum  electrodes,  for  high-fre- 
quency'  currents 143, 144 

Gocht,  the  form  of  the  ray-emitting 

area  of  anti-cathode 219 

Griffith,  on  electricity  in  the  treat- 
ment of  aneurisms 127 

Grisson's  resonator 185 

Grossman's  method  of  localization  of 

foreign  bodies  in  the  eye 297-298 

Ground  glass  substitute 232 

"Group"  arrangement  of  cells 41 

Grouven,  on  X-ray  action  on  diseased 

tissue 416 

Grove's  cell 03 

Grubbe,  on  the  X-rays  in  tuberculous 

adenitis 481 

Guilleminot,  his  instrument  for  cine- 

mato-radiographs 329 


534 


INDEX. 


Guilleminot,  on  the  measurement  of 
the  costal  angle 309 

Guilleminot-Courtade  method  of  mea- 
suring X-ray  dosage 438 


Hahn,  on  the  radiotherapy  of  eczema  451 
Halberstaedter,  on  sterilty  caused  by 

the  X-rays 412 

Hallopeau  and  Gadaud,  on  the  sclero- 

genic  action  of  the  X-rays 417 

Hard  tubes 195 

Hardening  the  negative 229 

Hare,  on  electricity  in  aneurisms.  .  .  .    128 
Haret,  on  the  X-ray  treatment  of  neu- 
ralgia    494 

Harris,  Sir  W.  Snow,  on  spark  length .    156 
Harrison's  method  for  the  localization 

of  foreign  bodies 302 

Hartigan,  on  radium  therapy  of  car- 
cinoma    509 

of  naevus 507 

Heliotropism 511 

Hemmeter's  method  in  skiagraphy  of 

the  stomach 340 

Henry,  the,  as  an  electrical  unit 38 

Herringham,  on  the  brachial  plexus 

in  the  new-born 88,  89 

Hertz,  on  high-vacua  discharges.  .  . .    157 

resonator  of 146 

Heiiman,  on  exophthalmic  goitre.  .  .  .    122 
Hewitt,  Cooper,  mercury  vapor  lamp 

of 516,517 

High-frequency  currents 138-155 

apparatus  for 139, 140 

D'Arsonval's 141 

Morton's 140 

Tesla'a 142 

electrodes  for 143-145 

history  of 138 

methods    of   application    of 

146-148 

auto-condensation 148 

direct  application. .    146,147 
indirect    application.  .  .    147 

local  application 148 

Oudin  resonator  for 143 

physical  properties  of ..    145,146 

dynamic  effects 145 

electro-static  effects.  .  .    145 

induction  effects 145 

resonance  effects ..        .    146 


High-frequency  currents,  physiologi- 
cal properties  of  ....    14\  1  lit 
treatment  by,  in  colitis.  . .  .    152 
in  dulness    of    hear- 
ing     154,  155 

in  epilepsy 153 

in  gonorrhoea 155 

in  gout 150 

in  hysteria 151 

in  lupus  vulgaris 151 

in  obesity 150 

in  ozaena 152 

in  piles,    rectal    fissure, 
and  pruritus  ani.  ...    151 

in  rheumatism 150 

in  rodent  ulcer  and  ma- 
lignant disease 151 

in  skin  diseases 154 

in  trachoma 154 

in  tuberculosis 149 

Hillard,  on  blue  light  as  an  anaesthetic  521 
Hint  in  using  coil  and  interrupter  in 

X-ray  therapy 420,  421 

Hints  for  practical  testing  in  electro- 
diagnosis 89 

Hirschmann's  monopol  tube 194 

Hirst,  on  the  limitations  of  galvanism 

and  faradism  in  gynaecology 122 

Histological  changes  induced  by  the 

action  of  the  X-rays 395-398 

Historical  sketch  of  the  rise  of  elec- 
tricity    29-31 

History  taking  in  skiagraphy 216 

Hoffa,  on  the  probability  of  X-ray 

dermatitis 402 

Hoffman's  measuring  stand  and  ex- 
amining frame 200 

Holland,   on  skiagraphing  a  case  of 

biliary  calculi 347 

Holtz'  influence  machine 49 

Holzknecht  and  Be"clere,  on  the  ob- 
lique   method  of    examination    of 

aneurisms 334 

Holzknecht  and  Brauner's  technic  in 

gastric  skiagraphy 340 

How  to  view  the  X-ray  negative.  .  .  .    234 
Hultz,  on  skiagraphy  of  the  stomach .   340 
Huntington,  on  the  pathological  phys- 
iology of  X-ray  dermatitis 404 

Hyde,  Montgomery,  and  Ormsby,  on 

radiotherapy  in  acne  rosacea 454 

in  psoriasis 456 


INDEX. 


535 


Hydraulic  analogy,  illustrating  poten- 
tial       34 

Hydro-electric  bath 77,  78 


Idiosyncrasy  to  static  current 55 

Immobilization  of  part  in  skiagraphy .   217 

Improvement  of  the  negative L'L'i) 

Independent  vibrating  hammer  inter- 
rupter     172 

Induction  coil 169 

construction  of 171 

Gaiffe 184 

Grisson 184 

Kinraide 181-183 

Tesla 180 

variable  primary  ("jumbo") 

178,  179 

without  interrupter 184 

Induction,  laws  of 169 

mechanism  of 170 

principles  of 71 

Influence  machine 46 

of  Holtz 49 

of  Voss  or  Toe  pier 50 

of  Wimshurst 47 

(See  Static  machine.) 
Influence    of    electricity    on    motor 

nerves  and  on  muscles 92 

of  photodynamic  substances  on 

the  action  of  the  X-rays 443 

of  radium  on  agglutination 502 

Installation  of  X-ray  apparatus  and 
the    management     of    its    various 

parts 204-207 

Intensifying  screens 220 

Interpretation  of  X-ray  negatives ....    234 

Interrupted  insulation 57 

Interrupter 73 

electrolytic 175 

Caldwell  and  Simon's 17.8 

Friedlander's 177 

W.-lmelfs 175,176 

mechanical 172 

Davidson's   rotary   contact- 
breaker 174 

disk 174 

independent  vibrating  ham- 
mer     172 

jet 175 

Johnston's 174 

platinum 172 


Interrupter,  mechanical,  self-starting  173 

Vril 17:! 

:   Intra-oral  method  in  dental  skiagra- 

Phy 370 

lonization  method  of  measuring  X- 
ray  dosage 436 


Jagn,  on  the  influence  of  radium  on 

agglutination 502 

Jameson,    on    the    radiotherapy    of 

xeroderma  pigmentosum 455 

Jaumann's    theories   of   the   cathode 

rays 159 

Jet  interrupter 175 

Johnston,  mercury  interrupter  of.  ...    174 
on  fluorescence  of  screen  as  a 

measurement  for  X-ray  dosage  440 
on  keratoses,  the  result  of  X-ray 

dermatitis 406 

Jones,  on  the  probable  physiological 
action  of  high-frequency  currents .  .    148 

Joule 38 

Jutassy,  on  the  X-rays  in  hypertricho- 
sis 447,  448 


Kaposi's  views  on  dermatitic  changes 

caused  by  the  X-rays 405 

Keen's  experiments  with  the  X-rays 

on  bacteria 389 

Kibbe,  on  the  histological  changes  in 

the  skin  due  to  the  X-rays 395 

Kienbock,  his  classification  of  the  de- 
grees of  vacuum.  .  .  .    196 
of  X-ray  dermatitis.  .  .  .    401 
his  experience  with  the  X-rays  in 

sarcoma 475 

quantimeter  of 434 

Kienbock  and  Benedikt,  on  the  X- 

rays  in  cerebral  affections 280 

Kohler,  his  thermometric  method  for 

X-ray  dosage 441 

Kothe,  on  the  influence  of  photody- 
namic substances  on  the  action  of 

the   X-rays 443 

Krause,  on  the  skiagraphic  examina- 
tion of  the  heart 332 

Kummel   and    RumpePs   conclusions 
on  renal  skiagraphy 354 


536 


INDEX. 


Labile  applications 67-68 

Lacaille's  apparatus  for  measuriug  X- 

ray  dosage 430 

Latent  stage  of  X-ray  dermatitis 401 

Laws  of  Faraday 169 

of  induction 169 

Lead  iris  diaphragm 221 

Leclanche's  cell 64 

Leduc,  on  the  electrolytic  introduc- 
tion of  salicylic  ions  in  cases  of 

neuralgia '. 117 

Lenard,  on  the  properties  of  cathode 

rays 157 

Leonard,      his      double-focus-tube 

method  for  localization 302 

his    prophylaxis    against    X-ray 

dermatitis 407 

on  renal  skiagraphy 353 

on  the  analgesic  action  of  the  X-- 
rays in  neuralgia 493, 494 

views  of,   concerning  X-ray  in- 
fluence on  diseased  tissue.  .  .  .   416 
Leukowitsch's    ophthalmological   ex- 
periments in  locating  foreign  bod- 
ies    289 

Leven  and  Barret,  on  a  study  of  the 
outlines  of  the  stomach  with  the 

fluoroscope 343 

Levy,  R.,  selenium  photometer  of .  . .  .   439 

Levy-Dorn's  orthodiagraph 328 

Leyden  jar 52 

"  Life  "  of  the  tube 198 

Light,  action  of,  on  bacteria 511,  512 

on  man 512 

on  plants 511 

for  photography 221 

nature  of 510,  51 1 

therapeutic  action  of 513 

treatment  by  artificial 514-521 

by  blue 520,521 

by  natural 514 

by  red 517-520 

Light-therapy  among  the  ancients.  .  .   513 
Liver,  fluoroscopic  examination  of .  .  .   346 

Local  reduction  of  the  negative 230 

Localized  faradization 74 

Lossen  and  Morawitz,  on  the  clinical 
and  histological  findings  in  leukae- 
mia, after  irradiation 486. 

Lovett  and  Brown,  on  X-rays  in  cox- 


M 
McGuire,  on  the  value  of  radiotherapy 

in  varicose  veins 457 

Macintyre,  on  the  X-rays  in  rhinology  367 

Magnetic  units 36 

Magnetism,  nature  and  properties  of.     33 
Manders,  on  radio-active  medication 

of  rheumatism 509 

on  the  X-rays  in  epilepsy 496 

Marie  and  Ribaut,  their  formulae  and 

table  f or  stereo-skiagraphy. .  .  .  246,  247 
Marx,  E.,  on  velocity  of  the  X-rays.  .  168 
Massey,  "The  Apostoli  Treatment  of 

Fibroids  " 77 

Matignon,  Maj.,  on  the  X-rays  in  war.   286 
Maxwell,  Clerk,  on  the  electro-mag- 
netic theory  of  light 156 

Mayo,  on  the  value  of  the  X-rays  in 

exophthalmic  goitre 490 

Mechanical  interrupters 172-175 

regeneration  of  vacuum  tubes.  ..    194 

Mechanism  of  induction 170 

Medical  and  surgical  affections  of  the 
kidney,  studied  skiagraphically .  .  .  .   351 

Medical  induction  coil 71-72 

Medico-legal  aspect  of  the  X-rays,  in 

relation  to  ossification  and  age  380 
aspect  of  X-ray  sterility.  .  .  .  387, 388 
considerations  of  the  X-rays  375-388 
questions  bearing  on  the  X- 

rays 379, 380 

Medium  tubes 195 

Methods  of  measuring  X-ray  dosage .  .    427 
(See  X-ray  dosage,  measure- 
ment of.) 

of  viewing  stereo-skiagrams.  .  .  .    249 
Meyer  and  Eisenreich,  on  the  X-ray 

treatment  of  leukaemia 483 

Mica  plates  for  static  machines 52 

Military  surgery,  X-rays  in 285,  286 

Milliamperage   of  the  secondary  in- 
duced current,  in  X-ray  dosage  427-429 

Milliamperemeter 66 

Mills'  views  concerning  the  electrical 

treatment  of  neurasthenia 120 

Minck  and  Gocht,  on  the  action  of  X- 

rays  on  typhoid  bacilli 390 

Minin's  views  on  the  anaesthetic  effect 

of  colored  light 520 

Modes  of  application  of  static  current .     57 
Modus  operand!  of  photographic  de- 
velopment     224-226 


INDEX. 


537 


Monopolar  bath 79 

Moritz,  orthodiagraph  of 325-328 

table  of,  showing  the  relation  be- 
tween the  size  of  the  heart  and 

stature 330 

views  of,   on  orthodiagraphy  in 

acute  cardiac  dilatation 331 

Morton,     "static     induced    current" 

high-frequency  apparatus  of.  .    140 
value  of  fluorescence  artificially 
produced    in    the    human 

body 442, 443 

wave  current  of 58,  59 

Moscowicz,  on  the  X-ray  treatment 

of  prostatic  hypertrophy 492 

Motor  points 81 

in  the  chest  and  abdomen.  .      87 

in  the  face 85 

in  the  lower  limb 85 

in  the  neck 85-87 

in  the  upper  limb 82-85 

Mounting  of  photographs 233 

Muffler,  for  the  static  machine 54 

Miiller's  regulation  tube 192 

Musham,  on  the  X-rays    in  general 
and  localized  tuberculosis 390 

N 

Nature  of  light 510,511 

of  radium   emanations 501 

Negative.      (See    Photographic   nega- 
tives.) 

Nerves  of  special  sense,  electrical  re- 
action  of 91 

New  radiometer  of  Freund,  for  meas- 
uring X-ray  dosage 435 

Newcomet's  device  for  simultaneous 
treatment  with  the  X-rays 424 

Newcomet  and  Krall,  on  the  X-ray 
treatment  of  a  case  of  trachoma .  .  .   488 


Occurrence  of  radium  in  nature 498 

Ohm 37 

Ohm's  law 39 

Orthodiagraph  of  Levy-Dorn 328 

of  Morwitz 325-328 

Orthodiagraphic    localizer    of 

Grashey 303-305 

Osmosis  regulating  tube 194 

Osteoscope  of  Beck 196 

Oudin,  resonator  of 143,  148 


Oudin,   Barthelemy,  and  Darier,  on 
alopecia  due  to  the 

X-rays 396 

on  cutaneous   changes 
due  to  the  X-rays.  .   405 


Pancoast,  on  the  X-rays  in  tubercu- 
losis    479,480 

"  Parallel "  arrangement  of  cells. ...   40,  63 
Pardo,  on  X-ray  treatment  of  tra- 
choma    488 

Partial  reaction  of  degeneration 91 

Pathological    physiology    of    electric 

currents  in  disease 98 

of  X-ray  dermatitis 404 

Pearce,  on  "  Epiphenonena  of  Cere- 
bral  Hemorrhage  " 281 

Pelvimetry,    as   studied   by   the    X- 

rays : 362-367 

Penetrability   of   urinary  calculi    by 

the  X-rays 350 

Penetration  method  of  studying  X- 

ray  dosage 429 

Penetration  of  radium 500 

Pennington,  on  irradiations  for  pru- 
ritus ani 455 

Permeability  of  the  X-rays 287 

Pfahler,  on  cerebral  skiagraphy 279 

on  value  of  X-rays  in  tubercu- 
losis    479 

Pfahler   and   Schamberg,    on    X-ray 

filters 426 

Pfliiger's  laws  of  contraction 92-93 

Philipp,  on  X-ray  sterility 413 

Phillips,  radio-active  standard  of.  ...   437 
Photographic  negatives,  drying  of .  .  .    228 
faulty,  causes  and  preven- 
tion of 231 

general  reduction  of 230 

hardening  of 229 

improvement  of 229 

local  reduction  of 230 

stains  and  spots  on 231 

washing  of 228 

(See  X-ray  negatives.) 
Photography,    accelerating   solutions 

employed  in 223 

author's  tank  for 228 

dark  room  for 221 

developers  employed  in 222,  223 

developing  papers  for 232 


538 


Photography,  dodging  in 'I'.l'l 

Envelo  developer  for ~~7 

fixing  in 227 

fixing  bath,  acid  chrome  for.  .  .  .    227 

ground-glass  substitute  in 232 

light  employed  in -21 

modus  operandi  of  development 

in 224-226 

mounting  in 233 

plates,  care  of  the,  in 222 

positives  in 233 

printing,   toning,   and   mounting 

in 231 

reducers  employed  in 222 

restraining  solution  used  in 224 

rules  in  handling  developers  for.   227 
sensitive  plates  and  films  in.  ...   222 

tank  development  in 226 

toning  process  in 233 

transparencies  and  lantern  slides 

in 234 

Photometric    methods   of   measuring 

X-ray  dosage 438 

Phototherapy 510-521 

Physical  properties  of  radium 500 

Physician's  responsibility  in  cases  of 

X-ray  burns 382-387 

Physico-chemical  method  for  measur- 
ing X-ray  dosage 431 

Physiological  action  of  radium 502 

Physiology,  uses  of  X-rays  in ....    255,  256 
Piffard,  his  principle  of  ionization  for 

X-ray  dosage 437 

Plastographic   method   in  stereo-ski- 

agraphy 250 

Plates    for   skiagraphy,   preparation, 

size,  protection,  etc.,  of 217,  218 

Platinum  interrupter 172 

Polar  method  of  examination  in  elec- 

t  ro-physiology 93 

Polarity  and  connections  of  the  X-ray 

tube 207,208 

of  the  battery 64 

of  the  static  current 54 

Porter,  on  the  degree  of  vacuum  of 

tubes 195 

Position  of  the  tube  and  patient  in 

fluoroscopic  examinations. 21 2,  213 
of  the  vacuum  tube  for  therapeu- 

sis 424 

Positives  in  photography 233 

Potential,  theory  of 34 


Precipitation  test,  for  measuring  X- 

ray  dosage 436 

Preparation  of  the  patient  for  screen 

examinations 211 

for   skiagraphic    exami- 
nations     216 

for  static  treatment ....      54 
Preutz,  on  skiagraphy  of  hepatic  ab- 
scess     278 

Prevention  of  the  secondary  or  Sag- 

nac  rays 220 

Preventive   measures    against    X-ray 

dermatitis 407 

Principles  of  induction 71 

Printing,  toning,  and  mounting 231 

Prostatic  calculi,  X-ray  examination 

of 360 

Protection   of  healthy   parts    during 

irradiation 422,  423 

of  operator  against  X-ray  derm- 
atitis     407,408 

Punctograph  for  the  localization  of 

foreign  bodies 299 

Puncture  of  the  anti-cathode 198 

Pusey,  on  the  radiotherapy  of  oesoph- 

agea!  carcinoma 469 

Pyelography 358 

Q 

Quality  of  the  X-rays 195,  220 

Quantimeter  of  Kienbock,  for  meas- 
uring X-ray  dosage 434 

Queirel  and  Acquavita,  on  the  evolu- 
tion of  the  osseous  system  skia- 
graphically  studied 366 

R 

Radio-active  standard  of  Phillips,  for 

measuring  X-ray  dosage 437 

Radiochromometer    of    Benoist,    for 

X-ray  dosage 429 

Radiometer  of  Courtade,  for  measur- 
ing X-ray  dosage 438 

of  Freund,  for  measuring  X-ray 

dosage 435 

of  Sabouraud  and  Noire" 432 

Radium,  bactericidal  action  of 501 

chemical    and    photographic    ef- 
fects of 498-500 

effects  of,  on  the  eye 502 

on  the  nervous  system 502 

fluorescence  and  luminosity  of.  .    500 


INDEX. 


539 


Radium,   influence  of,  on   agglutina- 
tion     502 

occurrence  of 498 

penetrating  power  of 500 

physical  properties  of .500 

physiological  action  of 502 

theoretical    considerations    con- 
cerning    501 

Radium  treatment  of  cutaneous  dis- 
eases     503-506 

of  exophthalmic  goitre 507 

of  naevus 507 

of  rabies 507 

Ransom,  on  the  X-rays  in  the  treat- 
ment of  tuberculosis 47',) 

Reaction  of  degeneration 90 

Reid,  on  a  new  method  in  renal  skiag- 
raph}'     357 

Remote  and  indirect  action  of  the  X- 

rays 412 

Remy's  method  for  the  localization  of 

foreign  bodies 300 

Renal  skiagraphy 352-355 

Reports  of  scientists  on  the  results  of 

Finsen's  method  in  smallpox 519 

Repumping  the  vacuum  tube 198 

Resonance,  as  a  factor  in  high-fre- 
quency studies 146 

Resonator,  Grisson's 185 

Hertz's 146 

Oudin's 143,146,148 

Restraining  solution 224 

Rheostat 66 

Rheotome 73 

Richardson,  on  "Electricity  in  Otol- 
ogy"      132-134 

Rieder,  action  of  the  X-rays  on  bac- 
teria     390,392,393 

technic  of,  in  gastric  skiagraphy.   340 
Rinehart,  on  the  necessity  of  produc- 
ing an  X-ray  dermatitis  for  the  cure 

of  disease 417 

Rockwell,    on    the    relation    between 

galvanism  and  cataphoresis ...      75 
on  the  treatment  of  suppuration 
of  the  middle  ear  by  the  gal- 
vanic current 131 

Rontgen,  Professor,  his  discovery  of 

the  X-rays 157 

sketch  of  the  life  of 157, 158 

Rontgen  apparatus.    (See  X-ray  ap- 
paratus.) 


Rontgen  rays.     (See  X-rays.) 

therapeutics.      (See   X-rays   in 

treatment,  etc.) 

Rudis-Jicinsky,  on  the  destructive  ac- 
tion of  the  X-rays  on  bac- 
teria   393 

on  the  X-rays  in  intestinal 
obstruction .   345 


S 


Sabouraud,  on  the  X-ray  treatment 
of  ringworm 450 

•>u  brazes  and  Riviere,  on  the  action 
of  the  X-rays  on  the  bacillus  pro- 
digiosus 391 

Salomonson,  on  the  measurement  of 
X-ray  dosage 428 

Sarcoma,  its  treatment  by  the  X- 
rays 473-477 

Sayen's  self-regulating  tube 190 

Scheppegrell,  on  the  radiotherapy  of 
laryngeal  carcinoma 470 

Schiff  and  Freund,  on  the  X-rays  in 
hypertrichosis 448 

Schnee's  battery  for  hydro-electro- 
therapy   80 

Scholtz,  on  changes  induced  in  dis- 
eased tissues  by  the  X- 

rays 415,416 

on  dermatitic  changes  due  to  the 
X-rays 397 

Schultze  and  Beck,  on  the  action  of 
X-rays  on  bacteria 390 

Schwartz,  precipitation  test  for  meas- 
uring the  strength  of  the  X-rays..  .  436 

Screen  method  for  the  localization  of 

foreign  bodies 299 

(See  Fluoroscope.) 

Secondary  batteries 41 

or  Sagnac  rays,  prevention  of .  .  .    220 

Selection  and  installation  of  X-ray 
apparatus 203-207 

Selenium  photometer  for  measuring 
X-ray  dosage 439 

Self-regulating  and  regenerative 
vacuum  tubes 189 

Self-starting  interrupter 173 

Senn,  on  the  X-ray  treatment  of  leu- 
kemia  483 

Sensitive  plates  and  films 222 

Sensory  system,  electrical  reactions  of     91 


540 


INDEX. 


Sequeira,    on    the    telangiectases    in 

dermatitic  X-ray  areas 406 

"  Series  "  arrangement  of  cells 40,  63 

Sharp,  on  the  thorium  treatment  of 

tuberculosis 508 

Shenton,  method  of,  for  the  localiza- 
tion of  foreign  bodies 301 

on  fluoroscopy  for   ureteral   cal- 
culi    356 

Shober's    radiode    for    radium    ther- 
apy     506,  509 

Shoemaker,   G.   E.,   a  study   of  the 
X-rays  in  a  case  of  sarcoma  of  the 

abdominal  wall 474 

Shoemaker,  J.   V.,  his  electrode  for 

prostatic  hypertrophy 113 

Silbergleit,  on  cardiac   (lateral)   dis- 
placement    329 

Sinusoidal  current 69 

Size,  shape,  and  intensity  of  image  on 

the  screen 213 

Sjorgen  and  Sederholm,  on  the  reac- 
tion of  blondes  and  brunettes  to  the 

X-rays 402 

Sketch  of  the  life  of  Wilhelm  Conrad 

Rontgen 157, 158 

Skiagraph,  differentiation  between  it 

and  an  ordinary  photograph 214 

Skiagrapher's  preparation  for  court .  .   378 

Skiagraphic  table 200 

Skiagraphy 214-218 

advantages  of  the  print  in 231 

data  on  the  negative  in 218 

immobilization  of  the  part  for.  .  .  217 
plates,  preparation,  size,  etc.,  for  217 
position  of  the  Crookes  tube 

in 216,219 

of  the  plate  for 216 

preparation  of  the  patient  for.  .  .   216 

synonyms  for  the  word 214 

(See  X-ray  diagnosis  and  treat- 
ment; also  Fluoroscopy.) 
Skiameters    and    penetrometers    for 

measuring  X-ray  dosage 431 

Skinner,  on  radiotherapy  of  a  sarco- 
ma of  the  abdominal  wall 475 

Snow,  on  the  electrical  treatment  of 

neurasthenia 121 

Soddy,  on  the  relative  values  of  radi- 
um and  thorium  therapy 502 

Soft,  medium,  and  hard  tubes 195,  422 

Solenoid,  auto-conduction  by 147 


Sormani,  on  the  action  of  the  X-rays 

on  bacteria 390 

Sources  of  electrical  energy 39 

Spintermeter    for    measuring    X-ray 

dosage 429 

Spinthariscope  for  studying  the  flu- 
orescence of  radium 500 

Sprengel,  Hermann,  invention  of  mer- 
cury air-pump 157 

Stabile  applications 67,  68 

Stains  and  spots  on  the  negative 231 

Starr,  on  the  relation  of  nerve  roots  to 

muscles 87-88 

Static  current,  dosage  of 56 

idiosyncrasy  to 55 

modes  of  application  of 57 

polarity  of 54 

preparation   of   the   patient 

for 54 

machine.      (See     Influence     ma- 
chine.)      46 

accessories  to 52 

advantages    of,    for    X-ray 

work 208 

care  and  manipulation  of .  .  .     51 
disadvantages     for     X-ray 

work 208 

electro-motive  force  of 52 

glass  plates  for 52 

mica  plates  for 52 

principles  of 46 

theory  of  action  of 48 

(For  the  various  forms  of 
static  current,  see  Static 
current,  modes  of  appli- 
cation of.) 

modalities,  chart  of 60-61 

Stationary  vacuum  tubes 189 

Steinwand,  on  X-ray  treatment  of  a 

case  of  pseudo-leuksemia 483-485 

Stephenson  and  Walsh,  on  the  X-ray 

treatment  of  trachoma 487 

Stereo-fluoroscopy 243 

and  skiagraphy,  history  and 

principles  of 242 

Stereoscopic  method  for  the  localiza- 
tion of  foreign  bodies 303 

Stereo-skiagraphy,  advantages  of.  ...   251 
author's  table  for  rearrang- 
ing negatives  for 248 

Brewster's  refracting  stereo- 
scope for 249 


IXDEX. 


541 


Stereo-skiagraphy,  history  and  prin- 
ciples of 242,  243 

methods  of  viewing  in 249 

plastographic  method  in.  ...    250 

technic  of 244-249 

AVheatstone's    reflecting 

stereoscope  for 249 

Sterility  caused  by  the  X-rays.  .  .   412—414 
Stern,  on  localizing  foreign  bodies  in 

the  eye 289 

Stokes,  Sir   G.  G.,  on  the    probable 

nature  of  X-rays 164,  165,  166 

Stomach,  behavior  of,  during  diges- 
tion, as  seen  by  the  X-rays.  .  .  .   342 
fluoroscopic  examination  of,  by 

bismuth  subnitrate.  .   338 

by  gaseous  distention.  .   337 

by  mechanical  means.  .   337 

by  transillumination.  .  .   341 

position  of,  as  seen  by  the  X-rays  342 

skiagraphic  examination  of 338 

time  of  exposure  in ....   339 
transillumination  meth- 
od in 341 

Storage  battery 41 

capacity  of 41 

care  of 41 

charging  of 41,  45 

Stover,  on    irradiations    in  cases   of 

kraurosis  vulvae 458 

Swain's  study  on  the  penetrability  of 

urinary  calculi 350, 351 

Sweet,  method  of,  for  localization  of 

foreign  bodies  in  the  eye .  .   290-295 
on  the  analgesic  action  of  the  X- 

rays 493 

Synonyms  for  the  word  "skiagraphy"  214 


Table,  skiagraphic 200 

author's 200 

Tank  or  slow  developing  photographic 

process 226 

Taylor,  on  the  medico-legal  aspect  of 

the  X-rays 379 

Technic  of  dental  skiagraphy 370 

of  medico-legal  skiagraphy.  377, 378 

of  renal  skiagraphy 352 

(For  detail  of  technic,  see  X-ray 
diagnosis;  X-rays  as  a  diagnos- 
tic agent;  X-rays  in  the  treat- 
ment of.) 


Tenny,  on  the  X-rays  in  cases  of  ure- 

teral  calculi 355 

Tesla,  high-frequency  apparatus  of .  .  .    142 
his   experiments    with    high-fre- 
quency currents 139 

oscillator  of 181-183 

Theory  of  potential 34 

Thermometric  method  for  measuring 

X-ray  dosage 441 

Thomson,  J.  J.,  on  radiant  matter.  . .  .    157 
Thomson,  Sir  William  (Lord  Kelvin) 
on  the  relation  between  gas  pressure 

and  spark  length 156 

Tizzoni,  on  the  radium  treatment  of 

rabies 507 

Toning  process 233 

Tousey,  newr  film-carrier  of,  for  dental 

skiagraphy 371, 372 

on  fluorescence,   in  conjunction 
with  the  X-rays,  in  stomachic 

examinations 342 

on  X-rays  in  tuberculosis 480 

Tracy,  on  high-frequency  currents  in 

epilepsy 153 

on  radio-active  treatment  with 

thorium 508 

Transformers 184 

Transparencies  and  lantern  slides  or 

diapositives 234 

Treatment  of  X-ray  dermatitis. .  .   408^12 
Triangulation  method  for  the  localiza- 
tion of  foreign  bodies 303 

Tube,  X-ray.     (See  Vacuum  tube.) 

Tube-holder 201 

author's 201 

Types  of  cells 63 

of  vacuum  tubes 189 


Units  of  electrical  measurement 36 

Unna,  on  microscopy  of  dermatitic 

X-ray  areas 405 

on  pigmentation  of  the  skin,  due 

to  the  X-rays 396 

Urinary  bladder,  X-ray  examination 

for  calculi  in 359 

Uskoff,  on  the  action  of  light  on  ciliary 
movement 512 


Vacuum  tube,  Bauer's 194 

blackening  of 197 


542 


Vacuum  tube,  Cald well's  cavity  ....    T_'l 

care  of 196, 197 

consumption  of 198 

Cossar's  cavity 424 

Crookes's 187,429 

position  of 216,221 

selection  of,  as   to  the 
requirements    of    the 

case 218 

degree  of  vacuum  of. ...    195, 196 
distance  of ,  from  the  plate ..    219 

in  therapeusis 424 

Ducretet's self-regulating.  .  .    192 
electro-static  regeneration  of  195 

essential  features  of 188 

explosion  of 198 

fluorescence  of,  and  appear- 
ance of  the  electrodes,  for 

X-ray  dosage 440 

hard,  soft,  and  medium.  .  .  .    195 

Hirschmann's  monopol 194 

life  of 198 

mechanical  regeneration  of.    194 

Muller's  regulation 192 

osmosis  regulation 194 

polarity  and  connections 

of 207, 208 

position  of,  for  therapeusis .  .    424 
puncture  of  anti-cathode  of .    198 

repumping  of 198 

Sayen's  self-regulating 190 

self-regulating  and  regener- 
ative     189 

stationary 189 

types  of 189 

ventril 197 

water-cooling 195 

Van  Allen,  on  the  value  of  the  X-rays 

in  lupus  vulgaris 446 

Variable  primary  induction  coils.  .  178,  179 
Varnier,  on  the  skiagraph  in  pelvim- 

etry 362,  363 

Vieruzhsky,  on  the  diagnosis  of  tuber- 
culosis by  the  X-rays 319 

Viewing-box  for  X-ray  negatives 236 

Villard,  remarks  of,  on  ventril  tubes.  .    197 
Violet  and  ultra-violet  rays  in  tuber- 
culosis    479, 480 

(See  Light.) 
Voelcker    and    Lichtenberg,    on    py- 

elography 358 

Volt 37 


Voltaic  alternatives 07-68 

Vose  and  Howe,  on  t  he  microscopy  of 

cancer  after  irradiation 419 

Voss  or  Toepler  influence  machine. ...     50 
Vril  interrupter 173 

w 

Wall  cabinet 64 

Walsham's  sign  in  aneurisms 334 

Walters,  on  X-ray  filters 426 

Washing  the  negative 228 

Water-cooling  vacuum  tubes 195 

Watt 38 

Wave  current 58 

Wehnelt's  interrupter 175,  176 

Wells,  on  the  multiple  connection  of 

Crookes  tubes  in  series 425 

Wet  cells 63 

Wheatstone's    reflecting    method    in 

stereo-skiagraphy 249 

White's  circular,  on  the  value  and 
medico-legal  relationship  of  the 

X-rays 380-382 

Wiedemann,  on  radiant  matter 157 

Wilkinson,  his  studies  of   the  X-rays 

in  leprosy 459 

Williams,  C.,  on  the  X-rays    in  the 

treatment  of  tuberculosis 478 

Williams,  F.,  fluorometer  of 438 

on  the  screen  examination  of 
the  normal  heart  and  dia- 
phragm   308 

on  the  skiagraph  in  pelvim- 

etry 365 

on  the  study  of  fifty  cases 
treated  with  radium  bro- 
mide   503,504 

Wimshurst  influence  machine 47 

Wolfenden  and  Ross,  on  the  action  of 
the  X-rays  on  the  bacillus  prodigi- 
osus.  .  .  390 


X-ray  apparatus,  hospital  outfit.  .  .  .    204 

portable  outfit 204 

selection,  care,  and  installa- 
tion of 203-207 

dermatitis 395 

acute  form  of 400 

causes  of 398,  399 

chronic  form  of 400 

classification  of. .  .   399 


INDEX. 


543 


X-ray    dermatitis,    duration    of    the 

chronic  form  of 406,  407 

frequency  and  susceptibility 

to,  and  latent  stage  of  401-404 
pathological    physiology 

of 404-406 

physician's  responsibility  in 

cases  of 382-387 

preventive  measures  against 

407,  408 
diagnosis  of  biliary  calculi . . .   346,  347 

of  prostatic  calculi 360,  361 

of  ureteral  calculi 355-359 

of  vesical  calculi.  .  .   350-355,  360 
(See  X-rays  as  a  diagnostic 

agent.) 

dosage,  the  measurement  of,  by 
chromoradio  meter 
of  Bordier.   433,  434 

of  Holzknecht 432 

by  Contremoulins' 

method 439 

by  cryptoradiometer  of 

Wehnelt 431 

by  current  to  the  pri- 
mary coil 427 

by  fluorescence  of  the 
tube  and  appearance 
of  the  electrodes.  .  .  .  440 

by  fluorometer 438 

by     Guilleminot  -  Cour- 

tade  method 438 

by  ionization  of  con- 
fined gases 436 

by  milliamperage  of  the 
secondary  induced 

current 427,  428 

by  precipitation  test .  .  .   436 
by  quantimeter  of  Kien- 

bock 434 

by  radio-active  stand- 
ard of  Phillips 437 

by  radiochromometer  of 

Benoist 429-431 

by  radiometer  of  Cour- 

tade 438 

of  Freund 435 

of  Sabouraud  and 

Noire 432,433 

by  selenium  photom- 
eter  439,  440 


X-ray  dosage,  the  measurement  of,  by 
skiameter  and   pene- 

trometer 431 

by  spintermeter 429 

by    the     thermometric 

method 441 

exposure,  factors  varying  time  of  220 
negative,  author's  examining  box 

for 236 

how  to  view 234,  235 

proper  light  for 235 

when  it  is  to  be  regarded  as 

satisfactory 234 

(See  Photographic  negative.) 
negatives,    interpretation   of,    in 
diseases    of   the    ali- 
mentary tract 240 

in  diseases  of  the  soft 

structures 238 

in  diseases  of  the  tho- 
rax  238-240 

in  diseases  and  tumors 

of  bone 238 

in  genito-urinary  affec- 
tions     240-242 

inlocatingforeign bodies  236 
X-rays,  action  of,  on  bacteria. .  .   389-395 

analgesic  action  of 493 

charging  action  of 168 

chemical  and  photographic  ef- 
fects of 166 

diagnosis  by.  (See  X-ray  diag- 
nosis; X-rays  as  a  diagnostic 
agent.) 

discovery  of 157 

fluorescence      and      phophores- 

cence  of 161,  162 

in  forensic  medicine 375-388 

in  military  surgery 285,  286 

physiological  effects  of 167 

production  of 160 

quality  of 220 

radiability  and  penetrability  of . .    160 
reflection,  refraction,  polarization 
and  interference  of.  .162,  163,  164 

table  of  permeability  of 287 

theories  accounting  for  the  proba- 
ble nature  of 167 

uses  of,  in  anatomy 252-255 

in  physiology 255,  256 

value  of,  in  a  differential  study  of 

bones  and  joints 258 


544 


INDEX. 


X-rays,  value  of,  in  fractures 259 

varieties  of  foreign  bodies,  as  re- 
gards    286 

velocity  of 168 

velocity  of  propagation  of. .  .    167, 168 

visibility  of 167 

X-rays  as  a  diagnostic  agent  in'callus 

formation 259,  260 

as  a  diagnostic  agent  in  dentis- 
try    372-374 

in  abscess  of  the  antrum  373 
in  alveolar  abscess.  .  .  .   374 
in  ankylosis  of  the  infe- 
rior maxillary  articu- 
lation    373 

in    detecting    pieces    of 

broken  instruments.  .   373 
in  fracture  of  the  infe- 
rior maxillary  bone .  .   373 
in  necrosis  of  the  max- 
illa    372 

in  orthodontia 374 

in  root-canal  fillings ....   373 

in  unerupted  teeth 372 

as  a  diagnostic  agent  in  diseases 
of  the  alimentary 

system 336-349 

of  the  intestine  344-346 
of  the  liver....   346,347 
of  the   oesopha- 
gus    336,337 

of  the  pancreas ....   348 

of  the  spleen 348 

as  a  diagnostic  agent  in  diseases 
of  the   bronchi 
and  lungs . .   313-321 
in  abscess  and  gan- 
grene    321 

in  acute  miliary  tu- 
berculosis    319 

in  asthma 314 

in  atelectasis 320 

in  bronchiectasis .  .   313 

in  bronchitis 313 

in  broncho  -  pneu- 
monia    315 

in  cavitation 318 

in  emphysema.  ...   315 

in  pneumonia 320 

in    pulmonary    tu- 
berculosis. . .  315-318 


X-rays  as  a  diagnostic  agent  in  dis- 
eases of  the  bronchi  and  lungs: 
in  thoracic  tumorsand  enlarged 

glands 323,324 

as  a  diagnostic  agent  in  diseases 
of  the  circulatory 

system 324-335 

in  aortic  aneurism .   333 

in  atheroma 335 

in  cardiac  atrophy, 
hypertrophy,  and 

dilatation 331 

in  dilatation  of  the 

aorta 335 

in  displaced  aorta.  330 
in  displaced  heart.  330 
in  enlarged  glands .  335 

in  neoplasms 335 

in  pericarditis 332 

in  pulsating  empy- 

ema 335 

as  a  diagnostic  agent  in  diseases 

of  the  joints 282-285 

as  a  diagnostic  agent  in  diseases 

of  the  pleura  321-324 

in  empyema 322 

in    hydro-pneumo- 
thorax  and  pyo- 
pneumothorax.  .   323 
in  pleurisy  with  ef- 
fusion  •.   321 

in  pneumothorax .  .    323 
in  subphrenic   ab- 
scess    323 

as  a  diagnostic  agent  in  frac- 
t  ures  and  disloca- 
tions   258-270 

of    the    lower    extrem- 
ity    266-270 

of  the  os  innominatum, 

sacrum,  and  coccyx.  .   270 
of  the  ribs  and  sternum .   272 
of  the  spinal  column.  .  .   271 
of  upper  extremity.  260-266 
as  a  diagnostic  agent  in  genito- 
urinary diseases  349-361 
in  closure  of  the  bladder  360 
in  prostatic  calculi .   360, 361 
i nureteral  calculi.  .   355-359 

in  vesical  calculi 360 

as   a  diagnostic    agent  in  gynae- 
cology and  obstetrics 362-367 


IXDKX. 


545 


X-rays  as  a  diagnostic  agent  in  intes- 
tinal affections. .   344-346 
in    abdominal    new 

growths 346 

in  obstruction 345 

in  rectal  imperf oration .   345 
in  sounding  and  radiog- 
raphy    344 

as  a  diagnostic  agent  in  osseous 
diseases,  tumors,  and 

deformities 272-277 

(See  X-rays  as  a  diag- 
nostic agent  in  frac- 
tures and  disloca- 
tions.) 

as  a  diagnostic  agent   in  patho- 
logical dislocations 270 

as  a    diagnostic    agent    in    rhi- 
nology,    laryngology, 
and  otology  ....   367-369 
in  abscess  of  the  antrum 

and  frontal  sinuses.  .   368 
in  abscess  of  the  mas- 

toid  process 369 

in  foreign  bodies  in  the 

ear 369 

in  foreign  bodies  in  the 

larynx 369 

in  ossification  of  the  la- 

ryngeal  cartilages . .  .   369 
as    a   diagnostic    agent    in    sto- 
machic affections  342-344 

in  gastroptosis 343 

in  stenosis  of  the  pylo- 
rus    344 

as  a  diagnostic  agent  in  tumors 

of  soft  tissues 277-282 

X-rays  in  the  treatment  of  constitu- 
tional diseases  477-487 
in  leukaemia.  .   482-487 
in  tuberculosis  477-482 
in  the   treatment  of    cutaneous 

affections  .  .   444—460 

of  acne 452 

of  acne  rosacea  453,  454 
of  acne  vulgaris .  .  .  453 
of  alopecia  areata .  447 


X-rays  in  the  treatment  of  cutaneous 
affections:  of  ec- 
zema    451 

of  favus  and  tinea 

tonsurans 449 

of  hyperidrosis  . .  .  458 
of  hypertricho- 

sis 447-449 

of  kraurosis  vulvae .   458 

of  leprosy 459 

of  lupus  erythema- 

tosus 444 

of  lupus  vulgaris . .   444 

of  njEVUs 446 

of  pruritus  ani  and 

vulvae 455 

of  psoriasis.  . .  456,  457 
of  senile  leg  ulcers .  457 

of  sycosis 454, 455 

of  varicose  veins. . .  457 
of  xeroderma  pig- 

mentosum . .   456,  457 
in  the    treatment    of  malignant 

growths 460-477 

in    carcinoma     of    the 

breast 465-469 

of  the  larynx 470 

of  the  oesophagus .  .  469 
of  the  sternum ....  469 
of  the  stomach  and 

intestines 470 

of  the  uterus. .   470,471 

in  sarcoma 473—477 

in  the  treatment  of  various  af- 
fections    487-495 

of  epilepsy 495 

of     exopthalmic 

goitre 490-492 

of   hypertrophied 

prostate 492 

of  keloid 489 

of  trachoma  .  .   487-489 


Zeisler,  on  the  radiotherapy  of  acne  453 
Zeit,  on  action  of  the  X-rays  on  bac- 
teria..  -   391 


.7.7 


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